The Centers for Medicare & Medicaid Services (CMS) has expressed significant
concerns with certain third parties, including hospitals, health care
providers, and other commercial entities, making premium payments or
copayments, deductibles, or other cost-sharing payments (collectively,
Cost-Sharing Payments) to health insurers for individual health plans on behalf
of enrolled individuals (?Members?).
Our position
Independence has a policy to not accept premium payments or other
Cost-Sharing Payments made by certain third parties, including, without
limitation, payments made directly or indirectly by a health care provider or
supplier.
Please carefully review Independence?s updated policy below to ensure that
you are not in violation of the policy. It should be noted that reimbursement
to health care providers or suppliers for services provided to such Members may
be subject to retroactive adjustments by Independence to the extent such
premium funding is or was in violation of this policy.
Our policy
The following policy applies to all Independence-participating providers.
This updated language will be incorporated into the Provider Manual for
Participating Professional Providers and Hospital Manual for
Participating Hospitals, Ancillary Facilities, and Ancillary Providers.
Direct and/or Indirect Third-Party Payments
of Member Premiums and
Cost-Sharing
Independence will not accept premium payments or Cost-Sharing
Payments made by third parties on behalf of its Commercial and Medicare Members
except as noted below.
Accepted Third-Party Payments
In accordance with applicable laws, regulations, and regulatory guidance,
this policy does not apply to premium payments or Cost-Sharing Payments made
by:
- the Ryan White HIV/AIDS Program under title XXVI of the PHS Act;
- an Indian tribe, tribal organization, or urban Indian organization; or
- a local, state, or Federal government program, including a grantee directed
by a government program to make payments on its behalf.
In addition, Independence will accept third-party payments:
- from family members.
- made by bona fide religious institutions and other bona fide not-for-profit
organizations only when each of the following criteria is met:
- the assistance is provided on the basis of the insured?s financial
need,
- the institution or organization is not a health care provider or
supplier,
- the premium payments and any Cost-Sharing Payments cover an entire policy
year, and
- the institution or organization does not have any direct or indirect
financial interests. For illustrative purposes only:
- a direct financial interest may exist if the third-party itself has a
financial interest in the payment of health insurance claims;
- an indirect financial interest may exist, for example, if the third-party
receives funding from other individuals or entities that have a financial
interest in the payments of the health insurance claims; and
- in the case of a nonprofit foundation or other charitable entity (including
without limitation a religious organization), a financial interest may exist if
the entity receives a financial contribution from a health care provider or
supplier.
In addition, Providers are required to comply with applicable rules and
regulations.
Violation of Policy
Independence will monitor third-party payments to assure compliance with
this policy and long-standing anti-fraud regulations. Any premium payments or
Cost-Sharing Payments received in violation of this policy will not be applied
to the Member?s benefit plan. If premium payments or Cost-Sharing Payments have
been made by third parties in violation of this policy, the Member will be
provided with an opportunity to secure alternative funding through qualified
sources. Reimbursement to health care providers or suppliers for services
provided to such Members may be subject to retroactive adjustment by
Independence to the extent such premium funding is or was in violation of this
policy or the earlier version of this policy.
Independence maintains sole discretion with respect to its acceptance of
third-party payments that are permitted under this policy and may make changes
to its administration of this policy at any time to the extent needed to
support compliance with the law and/or applicable regulatory guidance. This
policy may be updated from time to time.
Questions
If you have any questions regarding this policy, please contact your Network
Coordinator.