Over the past few years, various federal government agencies have issued new
rules, regulations, guidelines, and other guidance documents for the purpose of
implementing and clarifying the provisions of the Patient Protection and
Affordable Care Act, also known as Health Care Reform. One issue that has
recently been the subject of such guidance is whether, and to what extent,
third parties may make premium payments for health care coverage. This issue
had been the subject of long-standing, medical conflict-of-interest laws and
anti-fraud and abuse principles, prior to the passage of Health Care Reform;
these laws remain in effect as health plans, providers, and patients navigate
new provisions of Health Care Reform for health care delivery services.
Our position
AmeriHealth has analyzed the issue of whether certain third parties, such as
participating hospitals and other health care providers, are permitted to make
a payment on behalf of a member towards his or her premiums, copayments,
deductibles, or other cost-sharing payments. AmeriHealth concluded that
such a practice is not legally permitted under existing law and is inconsistent
with recent guidance from the Centers for Medicare & Medicaid
Services.
AmeriHealth is strongly committed to compliance with applicable federal and
state standards, including, but not limited to, regulatory and other
requirements (e.g., the Anti-Kickback Statute) and contractual commitments for
the federally funded programs in which we participate, including, but not
limited to, Medicare Advantage (Part C), Prescription Drug Program (Part D),
providing Qualified Health Plans on the federally facilitated Health Insurance
Marketplace, and other applicable Health Care Reform laws and regulations.
Consistent with not only the letter but the spirit of these laws, these
requirements also call for compliance by AmeriHealth providers who serve our
members.
Our policy
The following policy applies to all AmeriHealth-participating providers.
This language will be incorporated into the next update of our provider and
hospital manuals.
Direct and/or Indirect Third-Party Payments of Member Premiums and
Cost-Sharing
Except as noted below, AmeriHealth will not accept premium payments or
copayments, deductibles, or other cost-sharing payments (collectively ?Cost-
Sharing Payments?) by Providers on behalf of AmeriHealth?s enrolled
Members.
Subject to additional terms and conditions as determined by AmeriHealth in
accordance with applicable law, regulation, or regulatory guidance, this Policy
does not apply to premium payments or Cost-Sharing Payments made by:
- Indian tribes, tribal organizations, or urban Indian organizations;
- state and federal government programs or grantees (such as the Ryan White
HIV/AIDS Program); and
- bona fide charitable organizations unaffiliated with the Provider, or to
individuals and organizations related to the enrolled Members (i.e., family
member, friend, church, or employer) if they are made on behalf of a Member who
satisfies defined criteria that are based on financial status and do not
consider the Member?s health status, and so long as premiums and any
Cost-Sharing Payments cover the entire policy year.
Note that in accordance with AmeriHealth?s Policy, AmeriHealth will not
directly bill the organizations noted in (1), (2), and (3) above. AmeriHealth
will monitor third-party payments to assure compliance with this Policy and
long-standing anti-fraud regulations that remain unchanged under Health Care
Reform. AmeriHealth will not reimburse Providers for services rendered to its
Members in violation of this Policy. If premium payments or Cost-Sharing
Payments have been made by Providers in violation of this Policy, reimbursement
to Providers for services provided to such Members shall be subject to
retroactive adjustment by AmeriHealth.
Questions
If you have any questions regarding this policy, please contact your
Network Coordinator or Hospital/Ancillary Services Coordinator.