A letter signed by 184 members of Congress asking the U.S. Department of Health and Human Services Secretary to require insurance companies to accept charitable premium assistance would help dialysis providers regain their footing with patients enrolled in commercial health plans.

The May 29 letter, led by Representatives Kevin Cramer, R-N.D., and Doris Matsui, D-Calif., urges HHS Secretary Tom Price to issue a new policy that would require insurers to accept premium and cost sharing assistance from nonprofit charitable organizations, places of worship, and local civic organizations.

The policy would open the door to charitable contributions like the American Kidney Fund’s Health Insurance Premium Program (HIPP), which is funded largely by dialysis companies to help patients pay their health coverage premiums.

Last year, American Renal Associates and DaVita Kidney Care suspended support of the AKF’s premium assistance for Medicaid-eligible dialysis patients pursuing Affordable Care Act (ACA) exchange plans after the Centers for Medicare & Medicaid Services and the insurance industry accused dialysis providers of steering patients to more lucrative commercial plans. DaVita’s decision led to a loss of approximately $230 million for 2017.

A CMS rule that required dialysis providers to disclose to insurers when they were providing charitable funding of premiums to health plans was dismissed by a Texas judge because it didn’t allow for sufficient time for community review.

Letter urges HHS to overrule CMS policy

In 2014, CMS issued guidance that required Qualified Health Plans on the Federal Marketplace to accept payments from the Ryan White Aids Program, tribal organizations, and state and federal government entities. It didn’t require insurers to accept payments from charities like the AKF.

“The interim guidance is highly ambiguous and unclear, and some insurers have interpreted it as being a license to refuse all charitable premium payments for certain high-cost patients,” AKF CEO LaVarne Burton said in a written statement. “They are refusing charitable payments not just for exchange plans, but also for Medicare supplemental coverage and other insurance products.”

Dialysis providers and the AKF deny that they have steered patients.

“AKF continues to condemn anecdotal reports of health care providers ‘steering’ patients into private coverage by use of charitable assistance programs,” Burton said. “AKF continues to take strong actions to guard against such behavior in its own assistance program.”

In their letter, the Congressmen accuse the health insurers of doing the steering.

“For approximately three years this rule has encouraged Qualified Health Plans to discriminate against Americans with rare diseases, chronic illnesses and other catastrophic conditions by rejecting them on the basis of insurance premium and cost sharing assistance that they receive from nonprofit organizations. This practice essentially allows insurers to ‘steer’ patients to the government or other plans to avoid providing coverage.”

The CMS guidance only covers Qualified Health Plans on the Federal Marketplace, but the AKF told NN&I that insurers appear to be using it to justify dropping patients from other plans as well.

“They are refusing charitable payments not just for exchange plans, but also for Medicare supplemental coverage and other insurance products,” Burton said. “Patient advocacy groups have been urging HHS for three years to clarify the guidance so that legitimate, bona fide nonprofits like the American Kidney Fund can continue assisting patients as we have for many years.”

Representatives from DaVita said that 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 in an interview with NN&I. “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.

Representative Cramer, the lead author of the letter, sponsored a bill in 2015 that sought to allow non-profits, civic groups, and churches to help pay health insurance premiums for individuals and families.

“It’s hard to believe that – due to a 2014 CMS rule – a health plan is allowed to deny coverage to a chronically-sick patient just because they’re receiving donations from their local church or a nonprofit, but that’s what’s happening today in at least 41 states.” Cramer said in a written statement. “The federal government should overturn this rule and let charities be charitable. By allowing nonprofit charities to provide premium assistance to those most in need, we are providing a free market safety net for the most vulnerable among us to stay on health insurance. This practice should be encouraged, not discouraged.”