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Insights

Mar 19, 2014

HHS Publishes Interim Final Rule on Third Party Payments

Published

Mar 19, 2014

On March 14, HHS published an interim final rule on third party payments requiring qualified health plans (QHPs) and standalone dental plans (SADPs) to accept third party payments on behalf of enrollees from the Ryan White program, Indian tribes, tribal organizations, urban Indian organizations, and state and federal government programs.

The requirement applies to all individual market QHPs and SADPs, regardless of whether they are offered through a federally facilitated exchange (FFE), a state based exchange (SBE), or outside of the exchanges.

In some cases, which HHS notes will be addressed in future rulemaking, individuals may be eligible for special enrollment periods and a hardship exemption if the individual is unable to make their premium payment due to an issuer’s refusal to accept third party premium or cost sharing payments.

While CMS had previously issued FAQs recommending that issuers accept payments from the Ryan White program, tribal organizations, and state and federal government programs, this rule requires issuers to accept those payments. HHS gives itself enforcement abilities to penalize issuers who do not comply. An issuer offering a QHP or SADP through an FFE may be subject to a maximum penalty of $100 per day per each individual who is adversely affected by the issuer’s non-compliance with this rule.

The interim final rule does not address longstanding pharmaceutical manufacturer questions on whether foundations or other commercial third party entities may provide cost-sharing assistance for drugs to exchange enrollees, it does, however, improve the ability of HIV patients to afford their medications on the health insurance exchanges via state AIDs drug assistance programs (ADAPs) that wrap around the exchange coverage.

While previous HHS guidance discouraged issuers from accepting health status-based third-party payments from providers and, by extension, pharmaceutical manufacturers, that guidance is still available only in the form of recommendations. HHS remains concerned that third party payments provided by commercial entities could skew the insurance risk pool.

View HHS’ interim final rule here.

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