Even though a lawsuit halted the Centers for Medicare & Medicaid Services’ from implementing an interim final rule that would have made new regulations for dialysis facilities that make premium payments for patients on qualified health plans provided on the federal marketplace, the American Kidney Fund, and the dialysis providers who support its Health Insurance Premium Program (HIPP), cannot shake allegations of steering patients to more profitable private insurance plans.

BlueCross BlueShield of Tennessee (BCBST) implemented a policy at the beginning of the year that prohibits the American Kidney Fund (AKF) from paying premiums for dialysis patients who qualify under HIPP.

The policy requires non-profit organizations interested in paying premiums for individuals who purchase health insurance coverage from BCBST to apply for and receive approval from the insurer.

AKF CEO LaVarne Burton told NN&I that BlueCross BlueShield of Tennessee had accepted insurance payments directly from AKF on behalf of dialysis patients who have met the financial criteria for HIPP since 1997.

The majority of the AKF’s grants in Tennessee, and in all states, go to pay for Medigap supplemental insurance plans for low-income ESRD Medicare patients, Burton said. But they also make payments for employer group health plans, COBRA, and qualified health plans (QHPs).

Burton said the AKF applied with BCBST to request approval to make premium payments on behalf of BCBST subscribers, as required under the insurer’s new policy, but were denied with no explanation.

When asked, BlueCross BlueShield of Tennessee did not give NN&I a direct reason as to why they did not grant approval to the the American Kidney Fund, but a representative from the company did indicate that they generally don’t accept premium payments from organizations that provide assistance based solely on a medical condition or health status.

The representative also said they “instituted the new policy when it became evident that some organizations with a financial stake in providing certain types of care were steering patients, especially those who qualify for Medicaid and Medicare, into private insurance coverage for the purpose of financial gain. It’s a practice that drives up health care costs for all our members.”

Burton said the AKF has started sending premium payments directly to BCBST patients, but this imposes a severe hardship on many of them.

“We have heard from patients who do not have transportation and cannot get to a bank to deposit our checks; others do not even have bank accounts and must cash the checks, usually for a fee, and send a money order, also with a fee, to pay their premiums,” Burton said. “Some of the patients we serve are bedridden and get to dialysis by ambulance; others live alone and have no one to help them with errands.”

In its interim final rule issued in December 2016, CMS did make it clear that they believed the practice of dialysis providers steering patients for financial gain was widespread.

But dialysis providers contend that CMS requires them to provide education regarding insurance coverage and financial assistance programs.

“The previous administration explicitly asked many health care providers, including dialysis providers like DaVita, to post ACA information in their offices and clinics as part of their education efforts on the new options for patients,” a DaVita representative told NN&I in a recent interview.

“Even without such a request, CMS Conditions for Coverage required all dialysis providers to educate their patients about the new ACA plans.”

DaVita said they have heard from a number of patients who have been told by their insurers that they will no longer be able to use financial help from charities to pay their premiums.

“So far, most insurers engaged in this activity are only targeting patients on individual (or ACA) plans,” DaVita said. “Recently, however, we have seen the first example of an insurance company trying to use the same tactics to push patients out of their Medigap plans.

“This is particularly concerning, since the very same insurance companies often encourage their customers to opt into Medicare which has the effect of lowering the insurer’s costs. Yet without Medigap insurance, which covers the out-of-pocket costs imposed by Medicare, individuals who move to Medicare likely face payments as high as $10,000 or more in a single year.”

Burton said the AKF is working with the Tennessee insurance commissioner and other key stakeholders on the issue.

“BCBST appears to be applying guidance from a 2014 CMS interim final rule that requires insurers to accept payments from the Ryan White Aids Program, tribal organizations, and state and federal government entities,” Burton said.

“That same guidance does not preclude insurers from accepting payments from other nonprofits, and that guidance applies solely to QHPs—representing only about 5% of AKF patients in Tennessee. BCBST’s policy would appear to violate Tennessee law regarding Medigap, which does not permit insurers to be any more restrictive than the federal government.”