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August 22, 2016

CMS wants to stop providers from inappropriately steering patients into exchange plans

Daily Briefing

    CMS on Thursday requested public input on ways to prevent health care providers from steering patients who are eligible for Medicare or Medicaid into private exchange plans in order to receive higher payments.


    According to Reuters, plans sold through the Affordable Care Act's (ACA) exchanges typically pay health care providers and related organizations larger amounts for medical services than Medicare and Medicaid. Exchange plans also can cover different medications and procedures than Medicare and Medicaid.

    Health insurers participating in the exchanges have raised concerns that third-party organizations are encouraging high-cost patients who qualify for Medicare or Medicaid to enroll in exchange plans, such as by subsidizing those patients' premiums. The insurers argue the practice has skewed exchange plan risk pools.

    Is a regulatory 'loophole' letting ACA plans drop some high-cost patients?

    Acting CMS Administrator Andy Slavitt in a statement said, "We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients' needs." He added, "These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of [exchange] coverage for everyone."

    CMS seeks feedback

    CMS issued a request for information on ways to discourage providers and affiliated organizations from improperly steering patients into exchange plans. The agency said the request is "part of the [Obama] administration's ongoing work to strengthen and expand" the exchanges.

    Could ACOs be making health disparities worse?

    CMS said it is considering:

    • Imposing financial penalties on individuals who provide inaccurate information about a health plan in certain instances;
    • Limiting or prohibiting third-party payments for individuals' premiums or cost-sharing requirements; and
    • Limiting health care providers' payments for certain medical items or services at Medicare payment levels ; and
    • Revising Medicare and Medicaid provider enrollment policies.

    The agency said any imposed limits on third-party payments would not apply to certain local, state, or federal government programs, including Ryan White HIV/AIDS programs and tribal programs.

    CMS also sent letters to dialysis facilities participating in Medicare to inform them about the request. According to Modern Healthcare, UnitedHealth Group has filed a lawsuit claiming that one dialysis organization illegally directed money through a not-for-profit group to pay for patients' exchange premiums (Humer, Reuters, 8/18; Muchmore, Modern Healthcare, 8/18; Sullivan, The Hill, 8/18; CMS release, 8/18).

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