[Federal Register Volume 81, Number 240 (Wednesday, December 14, 2016)]
[Rules and Regulations]
[Pages 90211-90228]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-30016]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 494
[CMS-3337-IFC]
RIN 0938-AT11
Medicare Program; Conditions for Coverage for End-Stage Renal
Disease Facilities--Third Party Payment
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Interim final rule with comment period.
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SUMMARY: This interim final rule with comment period implements new
requirements for Medicare-certified dialysis facilities that make
payments of premiums for individual market health plans. These
requirements apply to dialysis facilities that make such payments
directly, through a parent organization, or through a third party.
These requirements are intended to protect patient health and safety;
improve patient disclosure and transparency; ensure that health
insurance coverage decisions are not
[[Page 90212]]
inappropriately influenced by the financial interests of dialysis
facilities rather than the health and financial interests of patients;
and protect patients from mid-year interruptions in coverage.
DATES: Effective date: These regulations are effective on January 13,
2017.
Comment date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on January 11, 2017.
ADDRESSES: In commenting, please refer to file code CMS-3337-IFC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed)
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-3337-IFC, P.O. Box 8010,
Baltimore, MD 21244-8010.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-3337-IFC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written comments ONLY to the following addresses prior to
the close of the comment period:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-9994 in advance to schedule your
arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as
appropriate for hand or courier delivery may be delayed and received
after the comment period. For information on viewing public comments,
see the beginning of the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Lauren Oviatt, (410) 786-4683, for
issues related to the ESRD Conditions for Coverage.
Lina Rashid, (301) 492-4103, for issues related to individual
market health plans.
SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments
received before the close of the comment period are available for
viewing by the public, including any personally identifiable or
confidential business information that is included in a comment. We
post all comments received before the close of the comment period on
the following Web site as soon as possible after they have been
received: http://regulations.gov. Follow the search instructions on
that Web site to view public comments.
Comments received timely will be also available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
A. Statutory and Regulatory Background
1. End-Stage Renal Disease, Medicare, and Medicaid
End-Stage Renal Disease (ESRD) is a kidney impairment that is
irreversible and permanent. Dialysis is a process for cleaning the
blood and removing excess fluid artificially with special equipment
when the kidneys have failed. People with ESRD require either a regular
course of dialysis or kidney transplantation in order to live.
Given the high costs and absolute necessity of transplantation or
dialysis for people with failed kidneys, Medicare provides health care
coverage to qualifying individuals diagnosed with ESRD, regardless of
age, including coverage for kidney transplantation, maintenance
dialysis, and other health care needs. The ESRD benefit was established
by the Social Security Amendments of 1972 (Pub. L. 92-603). This
benefit is not a separate program, but allows qualifying individuals of
any age to become Medicare beneficiaries and receive coverage. Under
the statute, individuals under 65 who are entitled to Medicare through
the ESRD program, or individuals over age 65 who are diagnosed with
ESRD while in Original Medicare, generally cannot enroll in Medicare
Advantage. Additionally, as access to Medigap policies is generally
governed by state law, individuals under age 65 who are entitled to
Medicare through the ESRD program cannot sign up for a Medigap policy
in many States.\1\
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\1\ Medigap policies are available to people under age 65 with
ESRD only in the following states: Colorado, Connecticut, Delaware,
Florida, Georgia, Hawaii, Illinois, Louisiana, Maine, Maryland,
Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New
Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon,
Pennsylvania, South Dakota, Tennessee, Texas, Oklahoma, and
Wisconsin.
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The ESRD Amendments of 1978 (Pub. L. 95-292), amended title XVIII
of the Social Security Act (the Act) by adding section 1881 of the Act.
Section 1881(b)(1) of the Act further authorizes the Secretary of the
Department of Health and Human Services (the Secretary) to prescribe
additional requirements (known as conditions for coverage or CfCs) that
a facility providing dialysis and transplantation services to dialysis
patients must meet to qualify for Medicare payment.
Medicare pays for routine maintenance dialysis provided by
Medicare-certified ESRD facilities, also known as dialysis facilities.
To gain certification, the State survey agency performs an on-site
survey of the facility to determine if it meets the ESRD CfCs at 42 CFR
part 494. If a survey indicates that a facility is in compliance with
the conditions, and all other Federal requirements are met, CMS then
certifies the facility as qualifying for Medicare payment. Medicare
payment for outpatient maintenance dialysis is limited to facilities
meeting these conditions. The ESRD CfCs were first adopted in 1976 and
comprehensively revised in 2008 (73 FR 20369). There are approximately
6,737 Medicare-certified dialysis facilities in the United States,
providing dialysis services and specialized care to people with ESRD.
In addition to Medicare, Medicaid provides coverage for some people
with ESRD. Many individuals enrolled in
[[Page 90213]]
Medicare may also qualify for full benefits under the Medicaid program
on the basis of their income, receipt of Supplemental Security Income,
being determined medically-needy, or other eligibility categories under
the State Plan. In addition, low income individuals enrolled in
Medicare may qualify for the Medicare Savings Program under which the
state's Medicaid program covers some or all of the individual's
Medicare premiums and, for some individuals, Medicare cost-sharing.
Finally, some individuals who are not eligible for enrollment in
Medicare may qualify for Medicaid.
According to data published by the United States Renal Data System
(USRDS), Medicare is the predominant payer of ESRD services in the
United States, covering (as primary or secondary payer) about 88
percent of the United States ESRD patients receiving hemodialysis in
2014. Among those enrolled in Medicare on the basis of ESRD and
receiving hemodialysis in 2015, CMS has determined 41 percent were
enrolled in both Medicare and Medicaid (including full and partial
duals). Among those enrolled in Medicare on the basis of ESRD under age
65, 51 percent were dual enrollees.
2. The Affordable Care Act and Health Insurance Exchanges
The Patient Protection and Affordable Care Act (Pub. L. 111-148)
was enacted on March 23, 2010. The Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152), which amended and revised
several provisions of the Patient Protection and the Affordable Care
Act, was enacted on March 30, 2010. In this interim final rule with
comment, we refer to the two statutes collectively as the ``Affordable
Care Act.''
The Affordable Care Act reorganizes and amends the provisions of
title XXVII of the Public Health Service Act (PHS Act) relating to
group health plans and health insurance issuers in the group and
individual markets. The Affordable Care Act enacted a set of reforms to
make health insurance coverage more affordable and accessible to
millions of Americans. These reforms include the creation of
competitive marketplaces called Affordable Insurance Exchanges, or
``Exchanges'' through which qualified individuals and qualified
employers can purchase health insurance coverage.
In addition, many individuals who enroll in qualified health plans
(QHPs) through individual market Exchanges are eligible for advance
payments of the premium tax credit (APTC) to make health insurance
premiums more affordable, and cost-sharing reduction (CSR) payments to
reduce out-of-pocket expenses for health care services. Individuals
enrolled in Medicare or Medicaid are not eligible for APTC or CSRs. The
Affordable Care Act also established a risk adjustment program and
other measures that are intended to mitigate the potential impact of
adverse selection and stabilize the price of health insurance in the
individual and small group markets.
The Public Health Service Act, as amended by the Affordable Care
Act, generally prohibits group health plans and health insurance
issuers offering group or individual health insurance coverage from
imposing any preexisting condition exclusions. Health insurers can no
longer charge different cost sharing or deny coverage to an individual
because of a pre-existing health condition. Health insurance issuers
also cannot limit benefits for that condition. The pre-existing
condition provision does not apply to ``grandfathered'' individual
health insurance policies.
Beginning January 1, 2014, the Affordable Care Act prohibited
insurers in the individual and group markets (with the exception of
grandfathered individual plans) from imposing pre-existing condition
exclusions. The Affordable Care Act's prohibition on pre-existing
condition exclusions enables consumers to access necessary benefits and
services, beginning from their first day of coverage. The law also
requires insurance companies to guarantee the availability and
renewability of non-grandfathered health plans to any applicant
regardless of his or her health status, subject to certain exceptions.
It imposes rating restrictions on issuers prohibiting non-grandfathered
individual and small group market insurance plans from varying premiums
based on an individual's health status. Issuers of such plans are now
only allowed to vary premiums based on age, family size, geography, or
tobacco use.
In previous rulemaking, CMS outlined major provisions and
parameters related to many Affordable Care Act programs. This includes
regulations at 45 CFR 156.1250, which require, among other things, that
issuers offering individual market QHPs, including stand-alone dental
plans, and their downstream entities, accept premium payments made on
behalf of QHP enrollees from the following third party entities (in the
case of a downstream entity, to the extent the entity routinely
collects premiums or cost sharing): (1) A Ryan White HIV/AIDS Program
under title XXVI of the PHS Act; (2) an Indian tribe, tribal
organization, or urban Indian organization; and (3) a local, state, or
Federal government program, including a grantee directed by a
government program to make payments on its behalf. This regulation made
clear that it did not prevent issuers from contractually prohibiting
other third party payments. The regulation also reiterated that CMS
discouraged premium payments and cost sharing assistance by certain
other entities, including hospitals and other health care providers,
and discouraged issuers from accepting premium payments from such
providers.\2\ Regulations at 45 CFR 156.1240 require issuers offering
individual market QHPs to accept payment from individuals in the form
of paper checks, cashier's checks, money orders, EFT, and all general-
purpose pre-paid debit cards. Regulations at 45 CFR 147.104 and 156.805
prohibit issuers from discriminating against or employing marketing
practices that discriminate against individuals with significant health
care needs.
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\2\ Patient Protection and Affordable Care Act; Third Party
Payment of Qualified Health Plan Premiums; Final Rule, 79 FR 15240
(March 14, 2014).
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3. Anti-Duplication
Individuals who are already covered by Medicare generally cannot
become concurrently enrolled in coverage in the individual market.
Section 1882(d)(3) of the Act makes it unlawful to sell or issue a
health insurance policy (including policies issued on and off
Exchanges) to an individual entitled to benefits under Medicare Part A
or enrolled under Medicare part B with the knowledge that the policy
duplicates the health benefits to which the individual is entitled.
Therefore, while an individual with ESRD is not required to apply for
and enroll in Medicare, once they become covered by Medicare it is
unlawful for them to be sold a commercial health insurance policy in
the individual market if the seller knows the individual market policy
would duplicate benefits to which the individual is entitled.\3\ CMS
has, moreover, solicited comments in a recent proposed rulemaking about
whether it is unlawful in most or all cases to knowingly renew coverage
under the same circumstances.\4\
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\3\ As discussed below, these anti-duplication standards--which
govern the conduct of insurance companies, not health care
providers--have not prevented inappropriate steering of individuals
eligible for Medicare to individual market plans.
\4\ Patient Protection and Affordable Care Act; HHS Notice of
Benefit and Payment Parameters for 2018; Proposed Rule, 81 FR 61455
(September 6, 2016).
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[[Page 90214]]
4. HHS Request for Information on Inappropriate Steering of Individuals
Eligible for or Receiving Medicare and Medicaid Benefits to Individual
Market Plans
HHS has recently become concerned about the inappropriate
``steering'' of individuals eligible for or entitled to Medicare or
Medicaid into individual market plans. In particular, HHS is concerned
that because individual market health plans typically provide
significantly greater reimbursement to health care providers than
public coverage like Medicare or Medicaid, providers and suppliers may
be engaged in practices designed to encourage individual patients to
forego public coverage for which they are eligible and instead enroll
in an individual market plan.\5\ In other words, health care providers
may be encouraging individual patients to make coverage decisions based
on the financial interest of the health care provider, rather than the
best interests of the individual patient. Further, as one tool to
influence these coverage decisions, health care providers may be
offering to pay for, or arrange payment for, the premium for the
individual market plan.
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\5\ Throughout this Interim Final Rule with Comment, the term
``public coverage'' is intended to refer to Medicare and Medicaid,
not to a group health plan or health insurance purchased in the
individual market in a state. A qualified health plan (QHP)
purchased through an Exchange is individual market coverage, not
public coverage.
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Based on these concerns, in August 2016, CMS issued a request for
information (RFI), titled ``Request for Information: Inappropriate
Steering of Individuals Eligible for or Receiving Medicare and Medicaid
Benefits to Individual Market Plans'', which published in the Federal
Register on August 23, 2016, seeking comment from the public regarding
concerns about health care providers and provider-affiliated
organizations steering people into coverage that was of financial
benefit to the provider, without regard to the impact on the patient
(81 FR 57554). In response to this RFI, we received over 800 public
comments by the comment closing date of September 22, 2016. Commenters
included: Patients; providers and provider-affiliated organizations
involved in the financing of care for patients; health insurance
companies; social workers who are involved in counseling patients about
potential health care coverage options; and other stakeholders. While
commenters discussed patients with a variety of health care needs, the
overwhelming majority of comments focused on patients with ESRD.
Comments indicated that dialysis facilities are involving
themselves in ESRD patients' coverage decisions and that this practice
is widespread. In addition, all commenters on the topic--including
insurance companies, dialysis facilities, patients, and non-profit
organizations--stated that they believe many dialysis facilities are
paying for or arranging payments for individual market health care
premiums for patients they serve.
Comments show that some ESRD patients are satisfied with their
current premium arrangements. In particular, more than 600 individuals
currently receiving assistance for premiums participated in a letter
writing campaign in response to the RFI and stated that charitable
premium assistance supports patient choice and is valuable to avoid
relying on ``taxpayer dollars.''
However, comments also documented a range of concerning practices,
with providers and suppliers influencing enrollment decisions in ways
that put the financial interest of the supplier above the needs of
patients. As explained further below, commenters detailed that dialysis
facilities benefit financially when individuals enroll in individual
market health care coverage. Comments also described that, even though
it is financially beneficial to suppliers, enrollment in individual
market coverage paid for by dialysis facilities or organizations
affiliated with dialysis facilities can lead to three types of harm to
patients: Negatively impacting their determination of readiness for a
kidney transplant, potentially exposing patients to additional costs
for health care services, and putting them at significant risk of a
mid-year disruption in health care coverage. Based on these comments,
HHS has concluded that the differences between providers' and
suppliers' financial interests and patients' interests may result in
providers and suppliers taking actions that put patients' lives and
wellbeing at risk.
B. Individual Market Coverage Is in the Financial Interest of Dialysis
Facilities
All commenters who addressed the issue made clear that enrolling a
patient in commercial coverage (including coverage in the individual
market) rather than public coverage like Medicare and/or Medicaid is of
significant financial benefit to dialysis facilities. For example, one
comment cited reports from financial analysts estimating that
commercial coverage generally pays dialysis facilities an average of
four times more per treatment ($1,000 per treatment in commercial
coverage, compared to $260 per treatment under public coverage). For a
specific subset of individual market health plans--QHPs--the analysts
estimated that the differential could be somewhat smaller, but that
QHPs would still provide an average of an additional $600 per treatment
when compared to public coverage. Based on these reports, dialysis
facilities would be estimated to be paid at least $100,000 more per
year per patient if a typical patient enrolled in commercial coverage
rather than public coverage, despite providing the exact same services
to patients. Another commenter estimated that a dialysis facility would
earn an additional $234,000 per year per patient by enrolling a patient
in commercial coverage rather than Medicaid ($312,000 per year rather
than $78,000 per year). A number of other commenters explained that
commercial coverage reimburses dialysis facilities at significantly
higher rates overall. These figures are consistent with other sources
of data. For example, USRDS data show that for individuals with ESRD
enrolled in Medicare receiving hemodialysis, health care spending
averaged $91,000 per individual in 2014, including dialysis and non-
dialysis services. By contrast, using the Truven MarketScan database, a
widely-used database of health care claims, we estimate that average
total spending for individuals with ESRD who are enrolled in commercial
coverage was $187,000 in 2014. In addition, recent filings with a
federal court by one insurance company concluded that commercial
coverage could pay more than ten times more per treatment than public
coverage ($4,000 per treatment rather than $300 per treatment).\6\
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\6\ Davita encouraged some low-income patients to enroll in
commercial plans; (Oct 23, 2016). http://www.stltoday.com/business/local/davita-encouraged-some-low-income-patients-to-enroll-in-commercial/article_ec5dc34e-ca4d-52e0-bc26-a3e56e1e2c85.html.
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As described, the comments in response to the RFI, data related to
CMS's administration of the risk adjustment program, and registry data
from the USRDS demonstrate that dialysis facilities can be paid tens or
even hundreds of thousands of dollars more per patient when patients
enroll in individual market coverage rather than public coverage. On
the other hand, the premiums for enrollment in individual market
coverage average $4,200 per year according to data related to CMS's
administration of the risk adjustment program. Dialysis facilities
therefore have much to gain financially (on the order of tens or even
hundreds of thousands of dollars per patient) by making a relatively
small outlay to pay
[[Page 90215]]
an individual's premium to enroll in commercial coverage so as to
receive a much larger payment for providing an identical set of health
care services. This asymmetry creates a strong financial incentive for
such providers to use premium payments to steer as many patients as
possible to commercial plans.
Commercial coverage pays at higher rates than public coverage for
many health care services, and therefore this pattern could
theoretically appear in a variety of contexts. Dialysis patients are,
however, particularly vulnerable to harmful steering practices for a
number of reasons. First, ESRD is the only health condition for which
nearly all patients are eligible to apply for and enroll in Medicare
coverage and with eligibility linked specifically to the diagnosis.
Thus, individuals with ESRD face a unique situation where they have
alternative public coverage options, but these coverage options may be
less profitable from the perspective of the facilities providing their
treatment due to lower reimbursement rates. Second, as described above,
patients with ESRD must receive services from a dialysis facility
several times per week for the remainder of their lives (unless and
until they obtain a kidney transplant). This sort of ongoing receipt of
specialized care from a particular facility is not typical of most
health conditions and it creates especially strong incentives and
opportunities for dialysis facilities to influence the coverage
arrangements of the patients under their care.
C. Individual Market Coverage Supported by Third Parties Places
Patients at Risk of Harm
Supporting premium payments to facilitate enrollment of their
patients in individual market coverage is, as illustrated above, in the
financial interest of the dialysis facilities. It is often not,
however, in the best interests of individual patients. The comments in
response to the RFI illustrated three types of potential harm to
patients that these arrangements create for ESRD patients: Negatively
impacting patients' determination of readiness for a kidney transplant,
potentially exposing patients to additional costs for health care
services, and putting individuals at significant risk of a mid-year
disruption in health care coverage.
While each of these potential harms is itself cause for concern,
they collectively underscore the complexity of the decision for a
patient with ESRD of choosing between coverage options, decisions that
have very significant consequences for these patients in particular.
The involvement of their providers in incentivizing, and steering them
to enroll in, individual market coverage is highly problematic absent
safeguards to ensure both that the individual is making a decision
fully informed of these complex tradeoffs and that the risk of a mid-
year disruption in health care coverage is eliminated. Each of these
specific potential harms to the patient is discussed further below.
1. Interference With Transplant Readiness
Access to kidney transplantation is a major and immediate concern
for many patients with ESRD; transplantation is the recommended course
of treatment for individuals with severe kidney disease, and is a life-
saving treatment, as the risk of death for transplant recipients is
less than half of that for dialysis patients. In addition to improving
health outcomes, receipt of a transplant can dramatically improve
patients' quality of life; instead of being required to undergo
dialysis several times per week, individuals who have received
transplants are able to resume a more typical pattern of daily life,
travel, and employment. Of the approximately 700,000 people with ESRD
in the United States, more than 100,000 are on formal waiting lists to
receive a kidney transplant. Further, in 2015 more than 80 percent of
kidney transplants went to patients under age 65, suggesting that
transplantation is of special concern to nonelderly patients, who are
most likely to be targeted by dialysis facilities for enrollment in
individual market coverage because they may not already be enrolled in
Medicare.
Therefore, any practice that interferes with patients' ability to
pursue a kidney transplant is of significant concern. Even a small
reduction in the likelihood of a patient receiving a transplant would
be detrimental to a patient's health and wellbeing. The comments in
response to the RFI support the conclusion that, today, enrollment in
individual market coverage for which there are third party premium
payments is hampering patients' ability to be determined ready for a
kidney transplant. Comments make clear that, consistent with clinical
guidelines, in order for a transplant center to determine that a
patient is ready for a transplant, they must conclude that the
individual will have access to continuous health care coverage. (This
is necessary to ensure that the patient will have ongoing access to
necessary monitoring and follow-up care, and to immunosuppressant
medications, which must typically be taken for the lifetime of a
transplanted organ to prevent rejection.) However, when individuals
with ESRD are enrolled in individual market coverage supported by third
parties, they may have difficulty demonstrating continued access to
care due to loss of premium support after transplantation. Documents in
the comment record indicate that major non-profits that receive
significant financial support from dialysis facilities will support
payment of health insurance premiums only for patients currently
receiving dialysis. Documents in the record show that these non-profits
will not continue to provide financial assistance once a patient
receives a successful kidney transplant, nor will the non-profit cover
any costs of the transplant itself, living donor care, post-surgical
care, post-transplant immunosuppressive therapy, or long-term
monitoring, which can cause significant issues for patients that cannot
afford their coverage without financial support. This policy is
consistent with the conclusion that these third party payments are
being targeted based on the financial interest of the dialysis
facilities who contribute to these non-profits, rather than the
patients' interests. Once a patient has received a transplant, it is no
longer in the dialysis facility's financial interest to continue to
support premium payments, although there are severe consequences to
individuals when that support ceases. If this occurs after
transplantation, individuals enrolled in individual market coverage
could be required to pay the full amount of the premium, which may be
unaffordable for many patients who previously relied on third party
premium assistance.
Theoretically, individuals could arrange for Medicare coverage to
begin at the time of transplantation, thereby demonstrating continued
access to care. In practice, however, patients struggle to understand
their coverage options and rapidly navigate the Medicare sign-up
process during a period where they are particularly sick and preparing
for major surgery. Some commenters to the RFI emphasized that this is
an extremely vulnerable group of patients who have difficulty
navigating their health insurance options. As evidenced by the rate of
dually eligible individuals discussed above, many ESRD patients are low
income and have limited access to the resources necessary to navigate
these sorts of coverage transitions, and patients are particularly
vulnerable during the short window when they are preparing for
transplants. Consistent with this, a number of comments describe how
these arrangements and patients' vulnerability and confusion
[[Page 90216]]
about alternative coverage both pre- and post-transplant have in fact
interfered with patients' care. For example, one comment describes a
family that was trying to obtain a transplant for a young child that
had to arrange other coverage on an emergency basis to obtain their
child's transplant. The family had allegedly been given inaccurate
information by a dialysis facility about their coverage options and how
private health insurance and Medicare would affect their child's
transplant. Another commenter employed by a transplant facility
described that ``many'' patients in individual market plans had ``their
transplant evaluations discontinued or delayed while they worked to
obtain appropriate and affordable insurance coverage.'' A number of
other social workers who submitted comments in response to the RFI also
identified these transplant access issues as a major concern.
2. Exposure to Additional Costs for Health Care Services
In addition to impeding access to transplants, enrollment in
individual market coverage, even when third parties cover costs, is
financially disadvantageous for some patients with ESRD. That is, while
it is in dialysis facilities' financial interest to support enrollment
in the individual market, those arrangements may cause financial harms
to patients that would have been avoided had the patients instead
enrolled in public coverage.
People with ESRD often have complex needs and receive care from a
wide variety of health care providers and suppliers. Data from USRDS
show that total health care spending per Medicare ESRD enrollee
receiving hemodialysis averaged more than $91,000 in 2014, but spending
on hemodialysis is only 32 percent of that amount, meaning that a
typical patient may incur thousands of dollars in costs for other
services. While some of the non-dialysis services these patients
receive may also be provided by their dialysis facilities, half or more
of Medicare spending on this population is for care that is likely
delivered by other providers and suppliers, including creation and
maintenance of vascular access, inpatient hospital care, skilled
nursing facility services, home health services, palliative services,
ambulance services, treatment for primary care and comorbid conditions,
and prescription drugs. Thus, when considering the financial impact of
coverage decisions, it is important to consider costs that a patient
will incur for services received that go beyond dialysis.
a. Eligibility for Medicaid
As described above, many people with ESRD are eligible for
Medicaid. Indeed, more than half of ESRD Medicare enrollees under age
65 are also enrolled in Medicaid.\7\ For many Medicaid enrollees, the
health care costs for which they are financially responsible are
negligible--and many face no cost-sharing or premiums at all. By
contrast, consumers in the individual market were responsible for out-
of-pocket costs up to $7,150 in 2017.\8\ As described above, much of
that out-of-pocket exposure is likely to be incurred outside of the
dialysis facility so, even if a provider or non-profit covers out-of-
pocket costs related to dialysis, enrolling in an individual market
plan rather than Medicaid exposes very-low income patients to thousands
of dollars in out-of-pocket costs.\9\ Indeed, given the Medicaid income
limits, this cost-sharing is likely to be an extraordinarily large
fraction of their income. Further, Medicaid includes coverage for
services not likely to be covered by individual market plans, such as
non-emergency medical transportation (which can vary based on the state
or type of Medicaid coverage), and patients will forego these benefits
if they instead enroll in the individual market. It is possible for an
individual to be enrolled in both Medicaid and individual market
coverage,\10\ and Medicaid would, in theory, wrap around the individual
market plan. Such an arrangement would be of great financial benefit to
the dialysis facility, but would be unlikely to provide financial
benefits to the individual (because the individual's cost sharing and
benefits would often be the same as if they had enrolled only in
Medicaid). Moreover, in practice, this arrangement creates a
significant financial risk for low-income individuals, who will need to
coordinate multiple types of coverage or else could find themselves
receiving large bills from health care providers and suppliers not
aware of their Medicaid coverage. Thus, it is very unlikely that it
would be in such individual's financial interest to elect individual
market coverage.
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\7\ This figure includes both individuals who are fully enrolled
in Medicare and Medicaid, and individuals enrolled in Medicare and
the Medicare Saving Program.
\8\ Patient Protection and Affordable Care Act; HHS Notice of
Payment and Benefit Parameters for 2017, (March 8, 2016); https://www.gpo.gov/fdsys/pkg/FR-2016-09-06/pdf/2016-20896.pdf.
\9\ Because these individuals are eligible for Medicaid, they
are generally prohibited from receiving cost-sharing reductions for
enrolling in coverage through an Exchange.
\10\ No APTC or CSR would be available to support enrollment in
the individual market in this circumstance.
---------------------------------------------------------------------------
b. Eligible for Medicare But Not Medicaid
For individuals with ESRD not eligible for Medicaid, enrolling in
the individual market rather than Medicare may also pose significant
financial risks. As noted above, these patients generally require
access to a wide variety of services received outside of a dialysis
facility. Patients with ESRD are generally enrolled in Original
Medicare (including Part A and Part B) and can therefore receive
services from any Medicare-participating provider or supplier. However,
unlike Original Medicare, which provides access to a wide range of
eligible providers and suppliers, and which has standard cost-sharing
requirements for all Medicare-eligible providers and suppliers,
individual market plans generally limit access to a set network of
providers that is more restrictive than what is available to an
Original Medicare beneficiary. If the individual sees providers or
suppliers outside of that network, they will incur higher cost-sharing
for necessary out-of-network services, and may have very limited
coverage for non-emergency out-of-network health care.
There may be other personal circumstances that lead to financial
burden caused by enrolling in an individual market plan rather than
Medicare. For example, individuals who are entitled to Part A and do
not enroll in Part B generally will incur a Part B late enrollment
penalty when they do ultimately enroll in Medicare Part B. Accordingly,
an individual who enrolls in Part A based on ESRD but does not enroll
in or drops Part B will generally be subject to a late enrollment
penalty should they decide to enroll in Part B later while still
entitled to Part A on the basis of ESRD. Individuals who receive a
kidney transplant may also face higher cost-sharing for
immunosuppressant drugs if they delay Medicare enrollment as
immunosuppressive drugs are covered under Part B only if the transplant
recipient established Part A effective with the month of the
transplant.
As noted above, for some members of this group, there is
potentially an offsetting financial benefit from individual market
coverage if total premiums and cost sharing are lower in an individual
market plan with third party premium assistance than in Medicare. In
particular, non-grandfathered individual markets plans are required to
cap total annual out-of-pocket expenditures for essential health
benefits at a fixed amount, the
[[Page 90217]]
maximum out-of-pocket limit, which is $7,150 in 2017. The individual
may not be able to cap their annual out-of-pocket expenses in Medicare;
while individuals over age 65 are eligible to enroll in Medicare
Advantage or Medigap supplemental plans, which do cap annual expenses,
individuals under age 65 with ESRD generally do not have such options
in many states.\11\ However, third party assistance is also frequently
available to offset out-of-pocket costs for Medicare enrollees.
Moreover, if dialysis facilities were not providing assistance for
individual market coverage on such a widespread basis, they might use
these resources to make assistance for out-of-pocket Medicare costs
even more widely available.
---------------------------------------------------------------------------
\11\ Congress recently passed legislation that would allow
people enrolled in Medicare on the basis of ESRD to select a
Medicare Advantage plan beginning in 2021.
---------------------------------------------------------------------------
3. Risks of Mid-Year Disruption in Coverage
Finally, the comments in response to the RFI demonstrate that there
is a significant risk of mid-year disruptions in coverage for patients/
individuals who have individual market coverage for which third parties
make premium payments. It is critically important that patients on
dialysis have continuous access to health care coverage. Prior to
transplantation this population requires an expensive health care
service several times per week in order to live; any interruption in
their access to care is serious and life-threatening. Moreover, as
noted, this group generally has health care needs beyond dialysis that
require care from a variety of medical professionals.
However, the comments reveal that patients/individuals who have
individual market coverage for which third parties make premium
payments are presently at risk of having their coverage disrupted at
any point during the year. CMS does not require that issuers accept
premium payments made by third parties except in certain circumstances
consistent with applicable legal requirements,\12\ and CMS has
consistently discouraged issuers from accepting payments directly from
health care providers.\13\ Many issuers have provisions in their
contracts with enrollees that are intended to void the contract if
payment is made by someone other than the enrollee. Issuers that
provided comments in response to the RFI confirmed that they do not
accept certain third party payments. One comment included a list of ten
states where major issuers are known to reject these payments when
identified. Comments from health care providers and non-profits
described that entities that make third party payments to issuers have
attempted to disguise their payments to circumvent detection by
issuers. These comments also described how issuers are increasingly
monitoring for and seeking to identify third party payments, and when
issuers discover those payments, they are rejected. The lack of
transparency around third party payments has therefore resulted in a
situation in which patients are at significant and ongoing risk of
losing access to coverage based on their issuer detecting payment of
their premiums by parties other than the enrollee.
---------------------------------------------------------------------------
\12\ 45 CFR 156.1250 requires issuers to accept third party
payment from federal, state and local government programs, Ryan
White/HIV Aids Programs and Indian Tribes, Tribal Organizations, and
Urban Indian Organizations.
\13\ Third Party Payments of Premiums for Qualified Health Plans
in the Marketplaces, November 4, 2013, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/third-party-qa-11-04-2013.pdf.
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When payments are rejected, commenters noted that individuals are
typically unable to continue their coverage because of the increased
financial burden. Indeed, patients may not even realize for some period
that their premiums, which are being paid by third parties, are being
rejected and that their coverage will be terminated if they do not have
an ability to pay themselves. HHS received 600 comments from ESRD
patients participating in a letter-writing campaign that describe the
adverse impact on patients receiving third party payment premium
assistance if those funds were no longer available. Other patients who
commented described significant and unexpected disruptions in coverage
such as no longer being able to afford the high cost of prescriptions
and office visit copays, delays receiving dialysis treatments, or no
longer being able to receive treatments. Due to the life-sustaining
nature of dialysis, dialysis facilities are not permitted to
involuntarily discharge patients, except in very limited circumstances.
However, one of those circumstances is lack of payment (42 CFR 494.180
(f)(1)). While we believe that such discharges are rare, and that
dialysis facilities try to avoid them, they are permitted. Moreover,
even when patients are able to enroll in other public coverage (which
may have retroactive effective dates) disruptions in coverage still
force patients to navigate a complicated set of coverage options. They
may face gaps in care or be forced to appeal health care claims.
Comments emphasized that many ESRD patients are low-income and do not
have a great deal of familiarity with the health care system, leaving
them more vulnerable to gaps in coverage. Therefore, any disruption in
coverage is problematic and can interrupt patient care.
In sum, the lack of transparency in how these payments are made and
whether or not they are accepted means that patients are at risk of
sudden gaps in coverage which may be dangerous to patients' health.
D. Conflict Between Dialysis Facilities' Financial Interest and
Patients' Interest Has Led to Problematic Steering
As described above, dialysis facilities have very meaningful
financial incentives to have their patients enroll in individual market
coverage rather than public coverage programs. However, enrollments in
individual market coverage are often not in patients' best interest: It
can complicate and potentially delay the process for obtaining a kidney
transplant; is often financially costly for patients, especially when
they are eligible for Medicaid; and places consumers at risk of a mid-
year coverage disruption. These risks make the task of deciding among
coverage options complex for ESRD patients. Furthermore, the asymmetry
between facilities' and patients' interests and information with
respect to enrollment decisions creates a high likelihood that a
conflict of interest will develop. Comments submitted in response to
the RFI support the conclusion that this conflict of interest is
harming patients, with dialysis facility patients being steered toward
enrollment in individual market coverage with third party premium
payments, rather than enrollment in the public coverage for which they
are likely eligible and which is frequently the better coverage option
for them.
Many comments were submitted by social workers or other
professionals who work or have worked with ESRD patients. Those
comments describe a variety of ways in which dialysis facilities have
attempted to influence coverage decisions made by patients or have
failed to disclose information that is relevant to determining
consumers' best interest. Specific practices described in comments
include:
Facilities engaging in systematic efforts to enroll people
in the individual market, often targeting Medicaid enrollees, without
assessing any personal needs. One commenter explained, ``My experience
was that the provider wanted anyone [who] was Medicaid only to be
educated about the opportunity to apply for an individual plan. . . .
The goal was 100%
[[Page 90218]]
education, whether there was an assessed need or not. . . . Valuable
hours of professional interventions were taken from direct patient care
concerns and diverted to this.'' Another explained, ``There was a list
of all Medicaid patients and the insurance management team was
responsible for documenting why the patient did not switch to an
individual market plan.'' Comments also described cases in which social
worker compensation was linked to enrolling patients in individual
market coverage.
Patients are not always informed about eligibility for
Medicare or Medicaid, or the benefits of those programs. For example,
one social worker explained, ``The patient is frequently not educated
about the benefits that are available with Medicaid (that is,
transportation, dental, and other home support services).'' Another
former social worker said that facility employees ``may not tell
patients that they could be subject to premium penalties and
potentially higher out-of-pocket costs than they would have with
traditional Medicare.'' Another commenter said, ``Enrollment counselors
offer no information about Medicare eligibility to members. In several
cases members were not aware that they were Medicare eligible.''
Patients are sometimes specifically discouraged from
pursuing Medicare or Medicaid. One commenter said: ``In the transplant
setting I have seen patients advised to delay in securing Medicare.''
Another employee at a dialysis facility relayed the story of a mother
seeking a transplant for her daughter but being told by a dialysis
facility not to enroll in Medicare. A transplant facility employee
explained ``In some circumstances, the patient has been encouraged to
drop their MediCal (Medicaid) coverage in favor of the individual
market plan, without having a full understanding of the personal
financial impact of doing so.''
Patients are unaware that a dialysis facility is seeking
to enroll them in the individual market and are not informed of this
fact by their health care providers. As one commenter said, ``In
numerous instances, these patients were already admitted at these
facilities, and interviews have found that many were unaware they had
insurance, let alone who was providing it.''
Patients are not informed about how their third party
premium support is linked to continued receipt of dialysis. For
example, one comment explained, ``People receiving assistance don't
realize that if they want a transplant the premiums will no longer get
paid.''
Facilities retaliate against social workers who attempt to
disclose additional information to consumers. One commenter explained
that they were ``reported to upper management of [dialysis
corporations] for voicing my concerns of the impact this [enrollment in
the individual market] will have on patients after transplant.''
Social workers are concerned that patients' trust in
health care providers is being manipulated to facilitate individual
market enrollment. For example, comments explained that insurance
counselors ``meet often with the patients establishing a relationship
of trust'' before pursuing individual market enrollment. A commenter
said, ``Most of us, who have some sophistication in health care
coverage, are aware of how confusing it is to negotiate the information
and reach the best decisions. Dialysis patients who may be less
sophisticated and already highly stressed are vulnerable to being
steered.'' Another commenter vividly explained, ``Patients . . . are in
a vulnerable position when they come to a dialysis facility. I hope
those of you reviewing these comments realize the power disequilibrium
which exists when a patient is hooked up with needles in their arm,
lifeblood running through their arms attached to a machine.''
In addition, HHS's own data and information submitted in response
to the RFI suggest that this inappropriate steering of patients may be
accelerating over time. Insurance industry commenters stated that the
number of enrollees in individual market plans receiving dialysis
increased 2 to 5 fold in recent years. Based on concerns raised in the
public comments in response to the RFI, we have reviewed administrative
data on enrollment of patients with ESRD. Information available from
the risk adjustment program in the individual market show that between
2014 and 2015, the number of individual market enrollees with an ESRD
diagnosis more than doubled.\14\ In some states increases were more
rapid, with some states seeing more than five times as many patients
with ESRD in the individual market in 2015 as in 2014. While increased
enrollment in the individual market among individuals who have ESRD is
not in itself evidence of inappropriate provider or supplier behavior,
these changes in enrollment patterns raise concerns that the steering
behavior commenters described may be becoming increasingly common over
time.
---------------------------------------------------------------------------
\14\ Risk adjustment applies to the entire individual market,
including plans offered on and off an Exchange.
---------------------------------------------------------------------------
E. HHS Is Taking Immediate Regulatory Action To Protect Patients
In the face of harms like those above, which go to essential
patient safety and care in life-threatening circumstances, HHS is
taking immediate regulatory action to prevent harms to patients. As
described in more detail below, we are establishing new Conditions for
Coverage standards (CfCs) for dialysis facilities. This standard
applies to any dialysis facility that makes payments of premiums for
individual market health plans (in any amount), whether directly,
through a parent organization (such as a dialysis corporation), or
through another entity (including by providing contributions to
entities that make such payments). Dialysis facilities subject to the
new standard will be required to make patients aware of potential
coverage options and educate them about the benefits of each to improve
transparency for consumers. Further, in order to ensure that patients'
coverage is not disrupted mid-year, facilities must ensure that issuers
are informed of and have agreed to accept the payments.\15\
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\15\ There are two potential ways to prevent mid-year
disruptions in coverage--either requiring issuers to accept these
payments or requiring facilities to disclose them and assure
acceptance. Both would equally promote continuity of coverage for
consumers. However, requiring issuers to accept payments in these
circumstances would destabilize the individual market risk pool, a
position CMS has consistently articulated since 2013, when we
expressly discouraged issuers from accepting these third party
payments from providers. The underlying policy considerations have
not changed and therefore CMS is seeking to prevent mid-year
disruption by requiring facilities to disclose payments and assure
acceptance.
---------------------------------------------------------------------------
This action is consistent with comments from dialysis facilities,
non-profits, social workers, and issuers that generally emphasized
disclosure and transparency as important components of a potential
rulemaking. By focusing on transparency, we believe we can promote
patients' best interests. CMS remains concerned, however, about the
extent of the abuses reported. We are considering whether it would be
appropriate to prohibit third party premium payments for individual
market coverage completely for people with alternative public coverage.
Given the magnitude of the potential financial conflict of interest and
the abusive practices described above, we are unsure if disclosure
standards will be sufficient to protect patients. We seek comments from
stakeholders on whether patients would be better off if premium
payments in this context were more strictly limited. We also seek
comment on alternative options where
[[Page 90219]]
payments would be prohibited absent a showing that a third party
payment was in the individual's best interest, and we seek comment on
what such a showing would require and how it could prevent mid-year
disruptions in coverage.
II. Provisions of the Interim Final Rule
Through this Interim Final Rule with comment (IFC) we are
implementing a number of disclosure requirements for dialysis
facilities that make payments of premiums for individual market health
plans, whether directly, through a parent organization, or through
another entity, to ensure proper protections for those patients. These
requirements are intended to ensure that patients are able to make
insurance coverage decisions based on full and accurate information.
As described in more detail below, we are establishing new CfC
standards for dialysis facilities. New standards apply to any dialysis
facility that makes payments of premiums for individual market health
plans (in any amount), whether directly, through a parent organization
(such as a dialysis corporation), or through another entity (including
by providing contributions to entities that make such payments). While
we remain concerned about any type of financial assistance that could
be used to influence patients' coverage decisions, we believe these
individual market premium payments are particularly prone to abuse
because they are so closely tied to the type of coverage an individual
selects. Further, as described above, such third party payments in the
individual market uniquely put patients at risk of mid-year coverage
disruption if their issuer discovers and rejects such payments.
Dialysis facilities subject to the new standards will be required to
make patients aware of potential coverage options and educate them
about certain benefits and risks of each. Further, in order to ensure
that patients' coverage is not disrupted mid-year, dialysis facilities
must ensure that issuers are informed of and have agreed to accept such
payments for the duration of the plan year.
A. Disclosures to Consumers: Patients' Right To Be Informed of Coverage
Options and Third Party Premium Payments (42 CFR 494.70(c))
In order to increase awareness of health coverage options for
individuals receiving maintenance dialysis in Medicare-certified
dialysis facilities, we are establishing a new patient rights standard
under the CfCs at 42 CFR 494.70(c). This new standard applies only to
those facilities that make payments of premiums for individual market
health plans (in any amount), whether directly, through a parent
organization (such as a dialysis corporation), or through another
entity (including by providing contributions to entities that make such
payments).
Dialysis facilities that do not make premium payments, and do not
make financial contributions to other entities that make such payments,
are not subject to the new requirements.\16\ We recognize that dialysis
facilities make charitable contributions to a variety of groups and
causes. This rule applies only to those dialysis facilities that make
payments of premiums for individual market health plans, whether
directly, through a parent organization, or through another entity.
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\16\ A facility that makes payments of premiums for individual
market coverage of its patients must comply with this standard.
Similarly, a facility that makes a financial contribution to another
organization, that is able to use the funds to make payments of
premiums for individual market coverage of some dialysis patients
must also comply, even when the contributions from the facility are
not directly linked to the premium payments; we note, moreover, that
mere recitation on a check that a contribution cannot be used for
premium payments would not establish that an organization is unable
to use the contribution for such payments. Further, an entity that
makes contributions through a third party that in turn contributes
to an entity that is able to use the contribution to make third
party premium payments will still be subject to these standards. In
contrast, a facility that does not make payments of premiums for
individual market coverage and does not contribute to any
organization that makes such payments, but does contribute to an
organization that supports premiums for Medicare enrollment, would
not be required to comply with this standard.
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At Sec. 494.70(c)(1), we detail the health insurance information
that must be provided to all patients served by applicable facilities.
These requirements establish that such information must cover how plans
in the individual market will affect the patient's access to and costs
for the providers and suppliers, services, and prescription drugs that
are currently within the individual's care plan, as well as those
likely to result from other documented health care needs. This must
include an overview of the health-related and financial risks and
benefits of the individual market plans available to the patient
(including plans offered through and outside the Exchange). This
information must reflect local, current plans, and thus would need to
be updated at least annually to reflect changes to individual market
plans. We expect that applicable dialysis facilities will meet this
requirement by providing the required information upon an individual's
admittance to the facility, and annually thereafter, on a timely basis
for each plan year.
While current costs to the patient are important, information about
potential future costs related to the current health plan selection
must also be addressed. In particular, we are requiring that coverage
of transplantation and associated transplant costs must be included in
information provided to patients. For example, some plans may not cover
all costs typically covered by Medicare, such as necessary medical
expenses for living donors. Kidney transplant patients who want
Medicare to cover immunosuppressive drugs must have Part A at the time
of the kidney transplant. Upon enrolling in Part B, Medicare will
generally cover the immunosuppressive drugs. Therefore, the beneficiary
must file for Part A no later than the 12th month after the month of
the kidney transplant. Entitlement to Part A and Part B based on a
kidney transplant terminates 36 months after the transplant. However, a
beneficiary who establishes Part A entitlement effective with the month
of the transplant is eligible for immunosuppressive drug coverage when
subsequent entitlement to Part B is based on age or disability.
Facilities must provide information regarding enrollment in Medicare,
and clearly explain Medicare's benefits to the patient. Facilities must
also provide individuals with information about Medicaid, including
State eligibility requirements, and if there is any reason to believe
the patient may be eligible, clearly explain the State's Medicaid
benefits, including the Medicare Savings Programs.
For other potential future effects, the facilities must provide
information about penalties associated with late enrollment (or re-
enrollment) in Medicare Part B or Part D for those that have Medicare
Part A as well as potential delays or gaps in coverage. Section 1839(b)
of the Act outlines the Medicare premium--Part A (for those who are not
eligible for premium-free Part A) and Part B late enrollment penalty.
Individuals who do not enroll in Medicare premium--Part A or Medicare
Part B when first eligible (that is, during their Initial Enrollment
Period) will have to pay a late enrollment penalty should they decide
to enroll at a later time. There are certain circumstances in which
individuals are exempt from the late enrollment penalty, such as those
who are eligible for Medicare based on Age or Disability, and did not
enroll when first eligible because they had or have group health plan
coverage based on their own or spouse's (or a family
[[Page 90220]]
member if Medicare is based on disability) current employment.
Although an ESRD diagnosis may establish eligibility for Medicare
regardless of age, it does not make individuals eligible for a Medicare
Special Enrollment Period or provide relief from the late enrollment
penalty. Thus, if an individual enrolls in Medicare Part A but does not
enroll in Part B, or later drops Part B coverage, that individual will
pay a Part B (and Part D) late enrollment penalty when ultimately
enrolling, or reenrolling, in Medicare Part B (and Part D).
Additionally, that individual will need to wait until the Medicare
General Enrollment Period to apply for Medicare Part B. The General
Enrollment Period runs from January 1 to March 31 each year, and Part B
coverage becomes effective July 1 of the same year. Thus, individuals
could face significant gaps in coverage while waiting for their
Medicare Part B coverage to become effective. We note that late
enrollment penalties and statutory enrollment periods do not apply to
premium-free Part A.
Information about potential costs to the patient is vitally
important for patients considering individual market coverage. An
individual may benefit in the short term by selecting a private health
plan instead of enrolling in Medicare, but patients must be informed
that those plans, or the particular costs and benefits of those plans,
may only exist for a given plan year, and that the individual may be at
a disadvantage (that is, late enrollment penalties for those that are
enrolled in Medicare Part A) should they choose to enroll in Medicare
Part B (or Part D) at a later date.
At Sec. 494.70(c)(2) and (3), we require that applicable
facilities provide information to all patients about available premium
payments for individual market plans and the nature of the facility's
or parent organization's contributions to such efforts and programs.
This information must include, but is not limited to, limits on
financial assistance and other information important for the patient to
make an informed decision, including the reimbursements for services
rendered that the facility would receive from each coverage option. For
example, if premium payments are not guaranteed for an entire plan
year, or funding is capped at a certain dollar amount, patients must be
informed of such limits. Facilities also must inform patients if the
premium payments are contingent on continued use of dialysis services
or use of a particular facility, and would therefore be terminated in
the event that the patient receives a successful kidney transplant or
transfers to a different dialysis facility. Further, facilities must
disclose to patients all aggregate amounts that support enrollment in
individual market health plans provided to patients directly, to
issuers directly, through the facility's parent organization, or
through third parties.
As with all patient rights standards for dialysis facilities, the
information and disclosures required in Sec. 494.70(c) must be
provided to all patients of applicable facilities, not just those new
to a facility who have not yet enrolled in Medicare or Medicaid. This
ensures that all patients are treated fairly and appropriately, and not
treated differently based on their health care payer, as required by
CMS regulations at 42 CFR 489.53(a)(2).
B. Disclosures to Issuers (42 CFR 494.180(k))
In conjunction with these requirements for patient information and
disclosures, we establish at Sec. 494.180(k), a new standard that
requires facilities that make payments of premiums for individual
market health plans, whether directly, through a parent organization,
or through another entity to ensure that issuers are informed of and
have agreed to accept the third party payments. Facilities should
develop reasonable procedures for communicating with health insurance
issuers in the individual market, and for obtaining and documenting
that the issuer has agreed to accept such payments. If an issuer does
not agree to accept the payments for the duration of the plan year, the
facility shall not make payments of premiums and shall take reasonable
steps to ensure that such payments are not made by any third parties to
which the facility contributes.
These requirements are intended to protect ESRD patients from
avoidable interruptions in health insurance coverage mid-year by
ensuring that they have access to full, accurate information about
health coverage options. We intend to outline expectations for
compliance in subsequent guidance. This rule does not alter the legal
obligations or requirements placed on issuers, including with respect
to the guaranteed availability and renewability requirements of the
Public Health Service Act and non-discrimination-related regulations
issued pursuant to the Affordable Care Act.\17\
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\17\ See 45 CFR 147.104, 156.225, 156.805.
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C. Effective Date
Because we are concerned that patients face risks that are not
disclosed to them, and that they may be at risk of disruptions in
coverage on an ongoing basis, we are taking action to ensure greater
disclosure to consumers and to provide for smooth and continuous access
to stable coverage when these rules are fully implemented. At the same
time, we are mindful of the need for dialysis facilities that make
payments of premiums for individual market health plans, whether
directly, through a parent organization, or through another entity, to
develop new procedures to comply with the standards established in this
rule. Therefore, the requirements in this rule will become effective
beginning January 13, 2017.
We note that, in specific circumstances, individuals may not be
eligible to enroll in Medicare Part A or Part B except during the
General Enrollment Period, which runs from January 1 to March 31 and
after which coverage becomes effective on July 1. These individuals may
experience a temporary disruption in coverage between the effective
date of the rule and the time when Medicare Part A and/or Part B
coverage becomes effective. In light of these circumstances, while the
standards under Sec. 494.180(k) will be effective beginning January
13, 2017, if a facility is aware of a patient who is not eligible for
Medicaid and is not eligible to enroll in Medicare Part A and/or Part B
except during the General Enrollment Period, and the facility is aware
that the patient intends to enroll in Medicare Part A and/or Part B
during that period, the standards under Sec. 494.180(k) will not apply
until July 1, 2017, with respect to payments made for that patient.
III. Waiver of Proposed Rulemaking and Delay in Effective Date
We ordinarily publish a notice of proposed rulemaking in the
Federal Register and invite public comment on the proposed rule in
accordance with 5 U.S.C. 553(b) of the Administrative Procedure Act
(APA) and section 1871(b)(1) of the Social Security Act. The notice of
proposed rulemaking includes a reference to the legal authority under
which the rule is proposed, and the terms and substance of the proposed
rule or a description of the subjects and issues involved. This
procedure can be waived, however, if an agency finds good cause that a
notice-and-comment procedure is impracticable, unnecessary, or contrary
to the public interest and incorporates a
[[Page 90221]]
statement of the finding and its reasons in the rule issued.
HHS has determined that issuing this regulation as a proposed
rulemaking, such that it would not become effective until after public
comments are submitted, considered and responded to in a final rule,
would be contrary to the public interest and would cause harm to
patients. Based on the newly available evidence discussed in section I
of this rule, that is, the responses to the August 2016 RFI, HHS has
determined that the widespread practice of third parties making
payments of premiums for individual market coverage places dialysis
patients at significant risk of three kinds of harms: Having their
ability to be determined ready for a kidney transplant negatively
affected, being exposed to additional costs for health care services,
and being exposed to a significant risk of a mid-year disruption in
health care coverage. We believe these are unacceptable risks to
patient health that will be greatly mitigated by this rulemaking, and
that the delay caused by notice and comment rulemaking would continue
to put patient health at risk. Given the risk of patient harm, notice
and comment rulemaking would be contrary to the public interest.
Therefore, we find good cause to waive notice and comment rulemaking
and to issue this interim final rule with comment. We are providing a
30-day public comment period.
In addition, we ordinarily provide a 60-day delay in the effective
date of the provisions of a rule in accordance with the APA (5 U.S.C.
553(d)), which requires a 30-day delayed effective date, and the
Congressional Review Act (5 U.S.C. 801(a)(3)), which requires a 60-day
delayed effective date for major rules. However, we can waive the delay
in the effective date if the Secretary finds, for good cause, that the
delay is impracticable, unnecessary, or contrary to the public
interest, and incorporates a statement of the finding and the reasons
in the rule issued (5 U.S.C. 553(d)(3).
In addition, the Congressional Review Act (5 U.S.C. 801(a)(3))
requires a 60-day delayed effective date for major rules. However, we
can determine the effective date of the rule if the Secretary finds,
for good cause, that notice and public procedure is impracticable,
unnecessary, or contrary to the public interest, and incorporates a
statement of the finding and the reasons in the rule issued (5 U.S.C.
808(2)).
As noted above, for good cause, we have found that notice and
public procedure is contrary to the public interest. Accordingly, we
have determined that it is appropriate to issue this regulation with an
effective date 30 days from the date of publication. As described
above, we believe patients are currently at risk of harm. Health-
related and financial risks are not fully disclosed to them, and they
may have their transplant readiness delayed or face additional
financial consequences because of coverage decisions that are not fully
explained. Further, consumers are at risk of mid-year coverage
disruptions. This is the time of year when patients often make
enrollment decisions, with Open Enrollment in the individual market
ongoing and General Enrollment Period for certain new enrollees in
Medicare about to begin on January 1. We have therefore determined that
the rule will become effective on January 13, 2017 to best protect
consumers.
IV. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 30-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. This
interim final rule with comment contains information collection
requirements (ICRs) that are subject to review by OMB. A description of
these provisions is given in the following paragraphs with an estimate
of the annual burden, summarized in Table 1. In order to fairly
evaluate whether an information collection should be approved by OMB,
section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires
that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
We are soliciting public comment on each of these issues for the
following sections of the interim final rule with comment that contain
ICRs. We generally used data from the Bureau of Labor Statistics to
derive average labor costs (including a 100 percent increase for fringe
benefits and overhead) for estimating the burden associated with the
ICRs.\18\
---------------------------------------------------------------------------
\18\ See May 2015 Bureau of Labor Statistics, Occupational
Employment Statistics, National Occupational Employment and Wage
Estimates at http://www.bls.gov/oes/current/oes_stru.htm.
---------------------------------------------------------------------------
1. ICRs Regarding Patient Rights (Sec. 494.70(c))
Under Sec. 494.70(c), HHS implements a number of requirements and
establishes a new patient rights standard for Medicare-certified
dialysis facilities that make payments of premiums for individual
market health plans, whether directly, through a parent organization,
or through another entity, to ensure proper protections for those
patients. Those applicable facilities will be required, on an annual
basis, to inform patients of health coverage options available to them,
including Medicare and Medicaid and locally available individual market
plans; enrollment periods for both Medicare and the individual market;
the effects each option will have on the patients access to, and costs
for the providers and suppliers, services, and prescription drugs that
are currently within the individual's ESRD plan of care and other
documented health care needs; coverage and anticipated costs for
transplant services, including pre- and post-transplant care; any funds
available to the patient for enrollment in an individual market health
plan, including but not limited to limitations and any associated risks
of such assistance; and current information about the facility's, or
its parent organization's premium payments for patients, or to other
third parties that make such premium payments to individual market
health plans for individuals on dialysis.
We assume that each applicable facility will develop a system to
educate and inform each ESRD patient of their options and the effects
of these options. For our purposes, we assume that each facility will
develop a pamphlet containing information that compares the benefits
and costs for each locally available individual market plan, Medicare,
and Medicaid, and display it prominently in their facility. In
addition, it is assumed that a facility staff such as a health care
social worker will review the required information with the patient and
answer any questions.
There are 6,737 Medicare-certified dialysis facilities. As
explained later in the regulatory impact analysis section, we estimate
that approximately 90 percent, or 6,064, facilities make payments of
premiums for individual market health plans, whether directly, through
a parent organization, or through another entity, and therefore, will
need to comply with these disclosure requirements. We estimate
[[Page 90222]]
that approximately 491,500 patients receive services at Medicare-
certified facilities. Therefore, on average, each facility provides
dialysis services to approximately 73 patients annually. While we
expect to detail in forthcoming guidance how dialysis facilities may
comply with these requirements, we are providing an example of one type
of disclosure, an informational pamphlet, to illustrate potential
costs. We note, that we expect dialysis facilities will use various
tools for disclosure including but not limited to informational
pamphlets, handouts, etc. It is estimated that each facility will
prepare, on average, a 6-page pamphlet that includes all required
information. We estimate that an administrative assistant will spend
approximately 40 hours (at an hourly rate of $37.86) on average to
research the required information and develop a pamphlet. We estimate
it will take an administrative manager (at an hourly rate of $91.20) 4
hours to review the pamphlet. The total annual burden for each facility
will be 44 hours with an equivalent cost of $1,879.20 ((40 hours x
$37.86 hourly rate) + (4 hours x $91.20 hourly rate)). In order to
print the pamphlet, we estimate that it will cost each facility $3.00
(for a 6-page pamphlet at $0.50 per page). For all 6,064 facilities,
the total annual burden will be 266,816 hours (44 hours x 6,064
facilities) with an equivalent cost of approximately $11,395,469
($1,879.20 annual burden cost x 6,064 facilities) and a total materials
and printing cost of $1,328,016. It is anticipated that the burden to
prepare the pamphlet will be lower in subsequent years since all that
will be needed is to review and update plan information. We estimate
that an administrative assistant will spend approximately 32 hours (at
an hourly rate of $37.86) on average to update the information in the
pamphlet, and it will take an administrative manager (at an hourly rate
of $91.20) 3 hours to review it. The total annual burden for each
facility will be 35 hours with an equivalent cost of approximately
$1,485 ((32 hours x $37.86 hourly rate) + (3 hours x $91.20 hourly
rate)). The total burden for all facilities will be 212,240 hours (35
hours x 6,064 facilities) with an equivalent cost of approximately
$9,005,768 ($1,485.12 annual burden cost x 6,064 facilities).
In addition to providing a copy of the pamphlet to the patients, it
is assumed that a health care social worker or other patient assistance
personnel at each facility will review the information with the
patients and obtain a signed acknowledgement form stating that the
patient has received this information. We estimate that a lawyer (at an
hourly rate of $131.02) will take 30 minutes to develop an
acknowledgement form confirming that the required information was
provided to be signed by the ESRD patient. The total burden for all
6,064 facilities to develop the acknowledgement form in the initial
year only will be 3,032 hours (0.5 hours x 6,064 facilities) with an
equivalent cost of approximately $397,253 (($131.02 hourly rate x 0.5
hours) x 6,064 facilities).
We estimate that a health care social worker (at an hourly rate of
$51.94) will take an average of 45 minutes to further educate each
patient about their coverage options. The social worker will also
obtain the patient's signature on the acknowledgement form and save a
copy of the signed form for recordkeeping, incurring a materials and
printing cost of $0.05 per form. The total annual burden for each
facility will be 54.75 hours (0.75 hours x 73 patients) with an
equivalent cost of approximately $2,844 ($51.94 hourly rate x 54.75
hours), and approximately $4 in printing and materials cost. The total
annual burden for all 6,064 facilities will be 332,004 hours 54.75
hours x 6,064 facilities) with an equivalent cost of approximately
$17,244,288 ($2,843.72 annual burden cost x 6,064 facilities), and
approximately $22,134 in printing and materials cost.
We will revise the information collection currently approved under
OMB Control Number 0938-0386 to account for this additional burden.
2. ICRs Regarding Disclosure of Third Party Premium Payments, or
Contributions to Such Payments, to Issuers (Sec. 494.180(k))
Under Sec. 494.180(k), HHS is implementing a requirement for those
dialysis facilities that make payments of premiums for individual
market health plans, whether directly, through a parent organization,
or through another entity, must ensure issuers are informed of and have
agreed to accept the payments for the duration of the plan year.
Based on comments received in response to the RFI, it is assumed
that approximately 7,000 patients that receive such payments are
enrolled in individual market plans. Therefore, we estimate that 6,064
facilities will be required to send approximately 7,000 notices. It is
assumed that these notices will be sent and returned electronically at
minimal cost. We estimate that, for each facility during the initial
year, it will take a lawyer one hour (at an hourly rate of $131.02) to
draft a letter template notifying the issuer of third party payments
and requesting assurance of acceptance for such payments. The total
annual burden for all facilities during the initial year will be 6,064
hours with an equivalent cost of approximately $794,505 ($131.02 x
6,064 facilities). This is likely to be an overestimation since parent
organizations will probably develop a single template for all
individual facilities they own. We further estimate that it will
require an administrative assistant approximately 30 minutes (at an
hourly rate of $37.86) to insert customized information and email the
notification to the issuer, send any follow-up communication, and then
save copies of the responses for recordkeeping. The total annual burden
for all facilities for sending the notifications will be 3,500 hours
(7,000 notifications x 0.5 hours) with an equivalent cost of $132,510
($37.86 hourly rate x 3,500 hours).
There are an estimated 468 issuers in the individual market. It is
assumed that the approximately 7,000 patients are uniformly distributed
between these issuers. Issuers will incur a burden if they respond to
the notifications from dialysis facilities and inform them whether or
not they will accept third party payments. It is estimated that it will
take a lawyer 30 minutes (at an hourly rate of $131.02) to review the
notification and an administrative manager 30 minutes (at an hourly
rate of $91.20) to approve or deny the request and respond to any
follow-up communication. It will further take an administrative
assistant approximately 30 minutes (at an hourly rate of $37.86) to
respond electronically to the initial notification and any follow-up
communications. The total annual burden for all issuers to respond to
7,000 notifications will be 10,500 hours (1.5 hours x 7,000
notifications) with an equivalent cost of $910,280 (10,500 hours x
$86.69 average hourly rate per notification per issuer).
We will revise the information collection currently approved under
OMB Control Number 0938-0386 to account for this additional burden.
[[Page 90223]]
Table 1--Annual Reporting, Recordkeeping and Disclosure Burden: First Year
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hourly
Burden Total labor Total capital/
Regulation section(s) OMB Number of Responses per annual cost of Total labor cost maintenance Total cost ($)
control No. respondents response burden reporting of reporting ($) costs ($)
(hours) (hours) ($)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Patient Rights (Sec. 0938-0386 6,064 442,672 44 266,816 $42.71 $11,395,468.80 $1,328,016.00 $12,723,484.80
494.70 (c)) 0 Pamphlets....
Patient Rights (Sec. 0938-0386 6,064 442,672 0.75 332,004 51.94 17,244,287.76 22,133.60 17,266,421.36
494.70 (c))--Patient
Education and Recordkeeping
Patient Rights (Sec. 0938-0386 6,064 6,064 0.5 3,032 131.02 397,252.64 0.00 397,252.64
494.70 (c))--
acknowledgement form.......
Disclosure of Third Party 0938-0386 6,064 6,064 1 6,064 131.02 794,505.28 0.00 794,505.28
Premium Assistance to
Issuers (Sec.
494.180(k))--letter
template...................
Disclosure of Third Party 0938-0386 6,064 7,000 0.5 3,500 37.86 132,510 0.00 132,510
Premium Assistance to
Issuers (Sec.
494.180(k))--notification
from facility..............
Disclosure of Third Party 0938-0386 468 7,000 1.5 10,500 86.69 910,280 0.00 910,280
Premium Assistance to
Issuers (Sec.
494.180(k))--issuer
response...................
---------------------------------------------------------------------------------------------------------------------------
Total................... ........... 6,532 911,472 48.25 621,916 481.24 30,874,304.48 1,350,149.60 32,224,454.08
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 2--Annual Reporting, Recordkeeping and Disclosure Burden: Subsequent Years
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hourly
OMB Burden Total labor Total labor cost Total capital/
Regulation section(s) control Number of Responses per annual cost of of reporting maintenance Total cost ($)
No. respondents response burden reporting ($) costs ($)
(hours) (hours) ($)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Patient Rights (Sec. 0938-0386 6,064 442,672 35 212,240 $42.43 $9,005,767.68 $1,328,016.00 $10,333,783.68
494.70 (c)) 0 Pamphlets....
Patient Rights (Sec. 0938-0386 6,064 442,672 0.75 332,004 51.94 17,244,287.76 22,133.60 17,266,421.36
494.70 (c))--Patient
Education and Recordkeeping
Disclosure of Third Party 0938-0386 6,064 7,000 0.5 3,500 37.86 132,510.00 0.00 132,510.00
Premium Assistance to
Issuers (Sec.
494.180(k))--notification
from facility..............
Disclosure of Third Party 0938-0386 468 7,000 1.5 10,500 86.69 910,280.00 0.00 910,280.00
Premium Assistance to
Issuers (Sec.
494.180(k))--issuer
response...................
---------------------------------------------------------------------------------------------------------------------------
Total................... ........... 6,532 899,344 37.75 558,244 218.93 27,292,845.44 1,350,149.60 28,642,995.04
--------------------------------------------------------------------------------------------------------------------------------------------------------
If you comment on these information collection requirements, please
do either of the following:
1. Submit your comments electronically as specified in the
ADDRESSES section of this interim final rule with comment; or
2. Submit your comments to the Office of Information and Regulatory
Affairs, Office of Management and Budget, Attention: CMS Desk Officer,
CMS-3337-IFC. Fax: (202) 395-6974; or Email:
[email protected].
V. Regulatory Impact Analysis
A. Introduction
This interim final rule with comment implements a number of
requirements for Medicare-certified dialysis facilities that make
payments of premiums for individual market health plans, whether
directly, through a parent organization, or through another entity. It
establishes a new patient rights standard applicable only to such
facilities that they must provide patients with information on
available health insurance options, including locally available
individual market plans, Medicare, Medicaid, and CHIP coverage. This
information must include the effects each option will have on the
patient's access to, and costs for the providers and suppliers,
services, and prescription drugs that are currently within the
individual's ESRD plan of care as well as those likely to result from
other documented health care needs. This must include an overview of
the health-related and financial risks and benefits of the individual
market plans available to the patient (including plans offered through
and outside the Exchange). Patients must also receive information about
all available financial assistance for enrollment in an individual
market health plan and the limitations and associated risks of such
assistance; including any and all current information about the
facility's, or its parent organization's contributions to patients or
third parties that subsidize enrollment in individual market health
plans for individuals on dialysis.
In addition, the interim final rule with comment establishes a new
standard requiring dialysis facilities that make payments of premiums
for individual market health plans, whether directly, through a parent
organization, or through another entity, to disclose these payments to
applicable issuers and requiring the contributing facility to obtain
assurance from the issuer that the issuer will accept such payments for
the duration of the plan year.
[[Page 90224]]
These requirements are intended to ensure that patients are able to
make coverage decisions based on full, accurate information, and are
not inappropriately influenced by financial interests of dialysis
facilities and suppliers, and to minimize the likelihood that coverage
is interrupted midyear for these vulnerable patients.
B. Statement of Need
This interim final rule with comment addresses concerns raised by
commenters and by HHS regarding the inappropriate steering of patients
with ESRD, especially those eligible for Medicare and Medicaid, into
individual market health plans that offer significantly higher
reimbursement rates compared to Medicare and Medicaid, without regard
to the potential risks incurred by the patient. As discussed previously
in the preamble, public comments received in response to the August
2016 RFI indicated that dialysis facilities may be encouraging patients
to move from one type of coverage into another based solely on the
financial benefit to the dialysis facility, and without transparency
about the potential consequences for the patient, in circumstances
where these actions may result in harm to the individual.\19\ Further,
enrollment trends indicate that the number of individual market
enrollees with ESRD more than doubled between 2014 and 2015, which is
not itself evidence of inappropriate behavior but does raise concerns
that the steering behavior described by commenters may be becoming
increasingly common, and without immediate rulemaking patients are at
considerable risk of harm.
---------------------------------------------------------------------------
\19\ Individuals who are already covered by Medicare generally
cannot become enrolled in coverage in the individual market. Section
1882(d)(3) of the Social Security Act makes it unlawful to sell or
issue a health insurance policy (including policies issued on and
off Exchanges) to an individual entitled to benefits under Medicare
Part A or enrolled under Medicare part B with the knowledge that the
policy duplicates the health benefits to which the individual is
entitled. Therefore, while an individual with ESRD is not required
to apply for and enroll in Medicare, once they become enrolled, it
is unlawful for them to be sold a commercial health insurance policy
in the individual market if the seller knows the individual market
policy would duplicate benefits to which the individual is entitled.
The financial consequences for patients moving from Medicare to
private insurance--including late enrollment penalties for
individuals in Medicare Part A but not Part B if they return to
Medicare, and lack of coverage for certain drugs following a kidney
transplant--are routinely not disclosed and may be unknown to
patients. These financial consequences can have significant impact
on patient care.
---------------------------------------------------------------------------
This interim final rule with comment addresses these issues by
implementing a number of requirements that will provide patients with
the information they need to make informed decisions about their
coverage and will help to ensure that their care is not at risk of
disruptions, gaps in coverage, limited access to necessary treatment,
or undermined by the providers' or suppliers' financial interests.
C. Overall Impact
We have examined the effects of this rule as required by Executive
Order 12866 (58 FR 51735, September 1993, Regulatory Planning and
Review), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub.
L. 96-354), section 1102(b) of the Social Security Act, the Unfunded
Mandates Reform Act of 1995 (Pub. L. 104-4), Executive Order 13132 on
Federalism, and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Order 12866 (58 FR 51735) directs agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects; distributive impacts; and equity). Executive
Order 13563 (76 FR 3821, January 21, 2011) is supplemental to and
reaffirms the principles, structures, and definitions governing
regulatory review as established in Executive Order 12866.
Section 3(f) of Executive Order 12866 defines a ``significant
regulatory action'' as an action that is likely to result in a rule--
(1) having an annual effect on the economy of $100 million or more in
any one year, or adversely and materially affecting a sector of the
economy, productivity, competition, jobs, the environment, public
health or safety, or state, local or tribal governments or communities
(also referred to as ``economically significant''); (2) creating a
serious inconsistency or otherwise interfering with an action taken or
planned by another agency; (3) materially altering the budgetary
impacts of entitlement grants, user fees, or loan programs or the
rights and obligations of recipients thereof; or (4) raising novel
legal or policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in the Executive Order. A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year.
We estimate that this rulemaking is ``economically significant'' as
measured by the $100 million threshold, and hence also a major rule
under the Congressional Review Act. Accordingly, we have prepared an
RIA that to the best of our ability presents the costs and benefits of
the rulemaking.
D. Impact Estimates and Accounting Table
In accordance with OMB Circular A-4, Table 3 below depicts an
accounting statement summarizing HHS' assessment of the benefits,
costs, and transfers associated with this regulatory action. The period
covered by the RIA is 2017 through 2026.
HHS anticipates that the provisions of this interim final rule with
comment will enhance patient protections and enable patients with ESRD
to choose health insurance coverage that best suits their needs and
improve their health outcomes. Providing patients with accurate
information will help to ensure that patients are able to obtain
necessary health care, reduce the likelihood of coverage gaps, as well
as provide financial protection. Dialysis facilities and issuers will
incur costs to comply with these requirements. If patients covered
through individual market plans opt to move to (or return to) Medicare
and Medicaid, then there will be a transfer of patient care costs to
the Medicare and Medicaid programs. For those patients covered through
individual market plans who chose to apply for and enroll in Medicare,
there would be a transfer of premium payments from individual market
issuers to the Medicare program. In accordance with Executive Order
12866, HHS believes that the benefits of this regulatory action justify
the costs.
Table 3--Accounting Table
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Benefits:
----------------------------------------------------------------------------------------------------------------
Qualitative:
* Provide patient protections and ensure that patients are able to make coverage decisions based on complete
and accurate information, and are not inappropriately influenced by the financial interests of dialysis
facilities.................................................................................................
[[Page 90225]]
* Improve health outcomes for patients by ensuring that patients have coverage that best fits both current
and future needs, including transplantation services.......................................................
* Ensure that issuers will accept any premium assistance payments for the duration of the plan year and
patients' coverage is not interrupted midyear..............................................................
----------------------------------------------------------------------------------------------------------------
Costs: Estimate Year dollar Discount Period
(millions) rate percent covered
----------------------------------------------------------------------------------------------------------------
Annualized Monetized........................ $29.1 2016 7 2017-2026
29.1 2016 3 2017-2026
----------------------------------------------------------------------------------------------------------------
Costs reflect administrative costs incurred by dialysis facilities and issuers to comply with ICRs.
----------------------------------------------------------------------------------------------------------------
Transfers:
Annualized Monetized........................ $688.4 2016 7 2017-2026
688.4 2016 3 2017-2016
----------------------------------------------------------------------------------------------------------------
Transfers reflect transfer of patient care costs from individual market issuers to Medicare and Medicaid; out-of-
pocket costs from dual eligible patients to Medicare and Medicaid; transfer of premium dollars from individual
market issuers to Medicare; and transfer of reimbursements from dialysis facilities to individual market
issuers if patients move from individual market plans to Medicare and Medicaid.
----------------------------------------------------------------------------------------------------------------
a. Number of Affected Entities
There are 6,737 dialysis facilities across the country that are
certified by Medicare, and an estimated 495,000 patients on dialysis.
Based on USRDS data for recent years, we estimated that approximately
99.3 percent or 491,500 patients receive services at Medicare-certified
facilities. Therefore, each Medicare-certified facility is providing
services to approximately 73 patients on average annually. As mentioned
previously, data indicates that about 88 percent of ESRD patients
receiving hemodialysis were covered by Medicare (as primary or
secondary payer) in 2014. Data from the CMS risk adjustment program in
the individual market (both on and off exchange) suggest that the
number of enrollees with an ESRD diagnosis in the individual market
more than doubled between 2014 and 2015. Although some of the increase
could be due to increases in coding intensity and cross-year claims,
the gross number is still significant and concerning. Comments received
in response to the RFI suggest that the inappropriate steering of
patients may be accelerating over time. Insurance industry commenters
stated that the number of patients in individual market plans receiving
dialysis increased 2 to 5 fold in recent years. We will continue to
analyze these data to better understand trends in ESRD diagnoses as
well as the extent to which individuals may be enrolled in both
Medicare and individual market plans and implications for the anti-
duplication provision outlined in section 1882(d)(3) of the Act.
There is no data on how many dialysis facilities make payments of
premiums for individual market health plans, whether directly, through
a parent organization, or through another entity. We believe that these
practices are likely concentrated within large dialysis chains that
together operate approximately 90 percent of dialysis facilities, and
therefore estimate that approximately 6,064 facilities make payments of
premiums for individual market health plans, whether directly, through
a parent organization, or through another entity.
b. Anticipated Benefits, Costs and Transfers
This interim final rule with comment implements a number of
requirements for Medicare-certified dialysis facilities (as defined in
42 CFR 494.10) that make payments of premiums for individual market
health plans (in any amount), whether directly, through a parent
organization (such as a dialysis corporation), or through another
entity (including by providing contributions to entities that make such
payments). Such facilities must provide patients with information on
available health coverage options, including local, current individual
market plans, Medicare, Medicaid, and CHIP coverage. This information
must include; the effects each coverage option will have on the
patient's access to, and costs for, the providers and suppliers,
services, and prescription drugs that are currently within the
individual's ESRD plan of care as well as those likely to result from
other documented health care needs. This must include an overview of
the health-related and financial risks and benefits of the individual
market plans available to the patient (including plans offered through
and outside the Exchange). Information on coverage of transplant-
associated costs must also be provided to patients, including pre- and
post-transplant care. In addition, facilities must provide information
about penalties associated with late enrollment in Medicare. Patients
must also receive information about available financial assistance for
enrollment in an individual market health plan and limitations and
associated risks of such assistance; the financial benefit to the
facility of enrolling the individual in an individual market plan as
opposed to public plans; and current information about the facility's,
or its parent organization's contributions to patients or third parties
that make payments of premiums for individual market plans for
individuals on dialysis.
These requirements are intended to ensure that patients are able to
make insurance coverage decisions based on full, accurate information,
and not based on misleading, inaccurate, or incomplete information that
prioritizes providers and suppliers' financial interests. It is likely
that some patients will elect to apply for and enroll in Medicare and
Medicaid (if eligible) instead of individual market plans once they are
provided all the information as required. As previously discussed,
Medicare (and Medicaid) enrollment will provide health benefits by
reducing the likelihood of disruption of care, gaps in coverage,
limited access to necessary treatment, denial of access to kidney
transplants or delay in transplant readiness, and denial of post-
surgical care. By enrolling in Medicare (and Medicaid), many
individuals can avoid potential financial loss due to Medicare late
enrollment penalties; higher cost-sharing, especially for out-of-
network services; higher deductibles; and coverage limits in individual
market plans. This is particularly true for the individuals eligible
for Medicare based on ESRD who are also eligible for
[[Page 90226]]
Medicaid. While a patient with individual market coverage could be
liable for out-of pocket costs of up to $7,150 in 2017, a patient
dually enrolled in Medicare and Medicaid will have very limited, and in
many cases no, out-of-pocket costs in addition to a wider range of
eligible providers and suppliers.
In addition, this interim final rule with comment establishes a new
standard, applicable only to facilities that make payments of premiums
for individual market health plans, whether directly, through a parent
organization (such as a dialysis corporation), or through another
entity (including by providing contributions to entities that make such
payments), requiring that the facility disclose such payments to
applicable issuers and obtain assurance from the issuer that they will
accept such payments for the duration of the plan year. This will lead
to improved health outcomes for patients by ensuring that coverage is
not interrupted midyear for these vulnerable patients, leaving them in
medical or financial jeopardy.
Dialysis facilities that make premium payments for patients as
discussed above will incur costs to comply with the provisions of this
rule. The administrative costs related to the disclosure requirements
have been estimated in the previous section.
If patients elect to apply for and enroll in Medicare and Medicaid
(if eligible) instead of individual market plans, the cost of their
coverage will be transferred from the patients and the individual
market issuers to the Medicare and Medicaid programs (if the patient is
eligible for both). This will lead to increased spending for these
programs. For the purpose of this analysis, we assume that
approximately 50 percent of patients enrolled in individual market
plans that receive third party premium payments will elect to apply for
and enroll in Medicare. USRDS data show that for individuals with ESRD
enrolled in Medicare receiving hemodialysis, total health care spending
averaged $91,000 per person in 2014, including dialysis and non-
dialysis services. Therefore, if 3,500 patients switch to Medicare, the
total transfer from individual market issuers to the Medicare program
will be approximately $318,500,000. We assume that about 50 percent of
patients that opt to enroll in Medicare will also be eligible for
Medicaid and will have negligible or zero cost-sharing, rather than the
maximum out-of-pocket cost of $7,150, which will be a transfer from the
patients to the Medicare and Medicaid programs. Therefore, for 1,750
dual eligible patients, the total transfer is estimated to be
$12,512,500. For those patients covered through individual market plans
who choose to enroll in Medicare there will also be a transfer of
premium payments from the individual market issuers to the Medicare
program. Assuming that patients will pay the standard Part B premium
amount, which will be $134 in 2017, and an average Part D premium of
$42.17,\20\ the total transfer for 3,500 patients is estimated to be
$7,399,140. In addition, if patients move from individual market plans
to Medicare, then reimbursements to dialysis facilities will be
reduced, since individual market plans currently have higher
reimbursement rates for dialysis services compared to Medicare,
resulting in a transfer from dialysis facilities to issuers. As
discussed previously, based on comments received, dialysis facilities
are estimated to be paid at least $100,000 more per year per patient
for a typical patient enrolled in commercial coverage rather than
public coverage. For 3,500 patients, the total transfer from dialysis
facilities to issuers is estimated to be at least $350,000,000.
---------------------------------------------------------------------------
\20\ Source: Jack Hoadley et al., Medicare Part D: A First Look
at Prescription Drug Plans in 2017, Kaiser Family Foundation,
October 2016, http://kff.org/medicare/issue-brief/medicare-part-d-a-first-look-at-prescription-drug-plans-in-2017/.
---------------------------------------------------------------------------
E. Alternatives Considered
Under the Executive Order, HHS is required to consider alternatives
to issuing rules and alternative regulatory approaches. HHS considered
not requiring any additional disclosures to patients. Providing complex
information regarding available coverage options may not always help
patients make the best decisions. In addition, disclosure requirements
may not be as effective where financial conflicts of interest remain
for the dialysis facilities. We also considered prohibiting outright
contributions from dialysis suppliers to patients or third parties for
individual market plan premiums, but determined that we wanted to have
additional data before implementing additional restrictions. A ban
could potentially cause financial hardship for some patients. On the
other hand, dialysis facilities would not be able to use these
contributions to steer patients towards individual market plans that
are more in the financial interests of dialysis facilities rather than
those of the patient. In the absence of additional data, it is not
possible to estimate the costs, benefits and transfers associated with
such a ban, whether the benefits would outweigh the costs, and whether
it would be more effective in ending the practice of steering.
HHS believes, however, that patients will benefit from having
complete and accurate information regarding their options, especially
information on Medicare and Medicaid and the financial and medical/
coverage consequences of each option. In addition, CMS can ensure
compliance with the disclosure requirements through the survey and
certification process. CMS plans to issue interpretive guidance and a
survey protocol for the enforcement of the new standards by state
surveyors to ensure that the facilities share appropriate information
with patients.
We also considered requiring issuers to accept all third party
premium payments. However, requiring issuers to accept such payments
could skew the individual market risk pool, a position CMS has
consistently articulated since 2013, when we expressly discouraged
issuers from accepting these premium payments from providers. We also
received comments from issuers, social workers, and others in response
to the RFI indicating that inappropriate steering practices could have
the effect of skewing the insurance risk pool. The underlying policy
considerations have not changed and therefore CMS is seeking to prevent
mid-year disruption by requiring facilities to disclose payments and
assure acceptance. In light of the comments received regarding dialysis
facilities' practices in particular, and the unique health needs and
coverage options available to this population, we are at this time
imposing disclosure-related obligations only on the ESRD facilities
themselves. This rule does not change the legal obligations or
requirements placed on issuers.
In addition, to determine whether further action is warranted, we
seek comments from stakeholders on whether patients would be better off
on balance if premium assistance originating from health care providers
and suppliers were more strictly limited and disclosed. We also seek
comment on alternative options where payments would be limited absent a
showing that the individual market coverage was in the individual's
best interest, and we seek comment on what such a showing would require
and how it could prevent mid-year disruptions in coverage.
F. Regulatory Flexibility Act
The Regulatory Flexibility Act (5 U.S.C. 601 et seq.) (RFA) imposes
certain requirements with respect to Federal rules that are subject to
the notice and comment requirements of section 553(b) of the
Administrative
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Procedure Act (5 U.S.C. 551 et seq.) and that are likely to have a
significant economic impact on a substantial number of small entities.
Unless an agency certifies that a rule is not likely to have a
significant economic impact on a substantial number of small entities,
section 604 of RFA requires that the agency present a final regulatory
flexibility analysis describing the impact of the rule on small
entities and seeking public comment on such impact.
The RFA generally defines a ``small entity'' as (1) a proprietary
firm meeting the size standards of the Small Business Administration
(SBA) (13 CFR 121.201); (2) a nonprofit organization that is not
dominant in its field; or (3) a small government jurisdiction with a
population of less than 50,000. (States and individuals are not
included in the definition of ``small entity.'') HHS uses as its
measure of significant economic impact on a substantial number of small
entities a change in revenues of more than 3 to 5 percent.
Because this provision is issued as a final rule without being
preceded by a general notice of proposed rulemaking, a final regulatory
analysis under section 604 of the Regulatory Flexibility Act (94 Stat.
1167) is not required. Nevertheless, HHS estimates that approximately
10 percent of Medicare-certified dialysis facilities are not part of a
large chain and may qualify as small entities. It is not clear how many
of these facilities make payments of premiums for individual market
health plans, whether directly, through a parent organization, or
through another entity. To the extent that they do so, these facilities
will incur costs to comply with the provisions of this interim final
rule with comment and experience a reduction in reimbursements if
patients transfer from individual market coverage to Medicare. However,
HHS believes that very few small entities, if any, make such payments.
Therefore, HHS expects that this interim final rule with comment will
not affect a substantial number of small entities. Accordingly, the
Secretary certifies that a regulatory flexibility analysis is not
required.
In addition, section 1102(b) of the Social Security Act requires
agencies to prepare a regulatory impact analysis if a rule may have a
significant economic impact on the operations of a substantial number
of small rural hospitals. This analysis must conform to the provisions
of section 604 of the RFA. This interim final rule with comment will
not affect small rural hospitals. Therefore, HHS has determined that
this regulation will not have a significant impact on the operations of
a substantial number of small rural hospitals.
G. Unfunded Mandates Reform Act
Section 202 of the Unfunded Mandates Reform Act (UMRA) of 1995
requires that agencies assess anticipated costs and benefits before
issuing any rule that includes a Federal mandate that could result in
expenditure in any one year by state, local or tribal governments, in
the aggregate, or by the private sector, of $100 million in 1995
dollars, updated annually for inflation. In 2016, that threshold level
is approximately $146 million.
UMRA does not address the total cost of a rule. Rather, it focuses
on certain categories of cost, mainly those ``Federal mandate'' costs
resulting from--(1) imposing enforceable duties on state, local, or
tribal governments, or on the private sector; or (2) increasing the
stringency of conditions in, or decreasing the funding of, state,
local, or tribal governments under entitlement programs.
This interim final rule with comment includes no mandates on state,
local, or tribal governments. Thus, this rule does not impose an
unfunded mandate on state, local or tribal governments. As discussed
previously, dialysis facilities that wish to make payments of premiums
for individual market health plans (in any amount), whether directly,
through a parent organization (such as a dialysis corporation), or
through another entity (including by providing contributions to
entities that make such payments), will incur administrative costs in
order to comply with the provisions of this interim final rule with
comment. Issuers will incur some administrative costs as well. However,
consistent with policy embodied in UMRA, this interim final rule with
comment has been designed to be the least burdensome alternative for
state, local and tribal governments, and the private sector.
H. Federalism
Executive Order 13132 outlines fundamental principles of
federalism. It requires adherence to specific criteria by Federal
agencies in formulating and implementing policies that have
``substantial direct effects'' on the states, the relationship between
the national government and states, or on the distribution of power and
responsibilities among the various levels of government.
This rule does not have direct effects on the states, the
relationship between the Federal government and states, or on the
distribution of power and responsibilities among various levels of
government.
I. Congressional Review Act
This interim final rule with comment is subject to the
Congressional Review Act provisions of the Small Business Regulatory
Enforcement Fairness Act of 1996 (5 U.S.C. 801 et seq.), which
specifies that before a rule can take effect, the Federal agency
promulgating the rule shall submit to each House of the Congress and to
the Comptroller General a report containing a copy of the rule along
with other specified information, and has been transmitted to the
Congress and the Comptroller General for review.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 494
Health facilities, Incorporation by reference, Kidney diseases,
Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services amends 42 CFR Chapter IV as follows:
PART 494--CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE
FACILITIES
0
1. The authority citation for part 494 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
0
2. Section 494.70 is amended by redesignating paragraph (c) as
paragraph (d) and adding a new paragraph (c) to read as follows:
Sec. 494.70 Condition: Patients' rights.
* * * * *
(c) Standard: Right to be informed of health coverage options. For
patients of dialysis facilities that make payments of premiums for
individual market health plans (in any amount), whether directly,
through a parent organization (such as a dialysis corporation), or
through another entity (including by providing contributions to
entities that make such payments), the patient has the right to--
(1) Be informed annually, on a timely basis for each plan year, of
all available health coverage options, including but not limited to
Medicare, Medicaid, CHIP and individual market plans. This must include
information on:
(i) How plans in the individual market will affect the patient's
access to, and costs for the providers and suppliers, services, and
prescription
[[Page 90228]]
drugs that are currently within the individual's ESRD plan of care as
well as those likely to result from other documented health care needs.
This must include an overview of the health-related and financial risks
and benefits of the individual market plans available to the patient
(including plans offered through and outside the Exchange).
(ii) Medicare and Medicaid/Children's Health Insurance Coverage
(CHIP) coverage, including Medicare Savings Programs, and how
enrollment in those programs will affect the patient's access to and
costs for health care providers, services, and prescription drugs that
are currently within the individual's plan of care.
(iii) Each option's coverage and anticipated costs associated with
transplantation, including patient and living donor costs for pre- and
post-transplant care.
(2) Receive current information from the facility about premium
assistance for enrollment in an individual market health plan that may
be available to the patient from the facility, its parent organization,
or third parties, including but not limited to limitations and any
associated risks of such assistance.
(3) Receive current information about the facility's, or its parent
organization's, contributions to patients or third parties that
subsidize the individual's enrollment in individual market health plans
for individuals on dialysis, including the reimbursements for services
rendered that the facility receives as a result of subsidizing such
enrollment.
* * * * *
0
3. Section 494.180 is amended by adding a new paragraph (k) to read as
follows:
Sec. 494.180 Condition: Governance.
* * * * *
(k) Standard: Disclosure to Insurers of Payments of Premiums. (1)
Facilities that make payments of premiums for individual market health
plans (in any amount), whether directly, through a parent organization
(such as a dialysis corporation), or through another entity (including
by providing contributions to entities that make such payments) must--
(i) Disclose to the applicable issuer each policy for which a third
party payment described in this paragraph (k) will be made, and
(ii) Obtain assurance from the issuer that the issuer will accept
such payments for the duration of the plan year. If such assurances are
not provided, the facility shall not make payments of premiums and
shall take reasonable steps to ensure such payments are not made by the
facility or by third parties to which the facility contributes as
described in this paragraph (k).
(2) If a facility is aware that a patient is not eligible for
Medicaid and is not eligible to enroll in Medicare Part A and/or Part B
except during the General Enrollment Period, and the facility is aware
that the patient intends to enroll in Medicare Part A and/or Part B
during that period, the standards under this paragraph (k) will not
apply with respect to payments for that patient until July 1, 2017.
Dated: November 28, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: November 29, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-30016 Filed 12-12-16; 4:15 pm]
BILLING CODE 4120-01-P