[Federal Register Volume 88, Number 132 (Wednesday, July 12, 2023)]
[Notices]
[Pages 44281-44290]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-14726]


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CONSUMER FINANCIAL PROTECTION BUREAU

[Docket No. CFPB-2023-0038]

DEPARTMENT OF HEATH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Docket No. CMS-2023-0106]

DEPARTMENT OF THE TREASURY

[Docket No. TREAS-DO-2023-0008]


Request for Information Regarding Medical Payment Products

AGENCY: Consumer Financial Protection Bureau (CFPB), Centers for 
Medicare & Medicaid Services, Department of Health and Human Services 
(HHS), and Department of the Treasury (Treasury).

ACTION: Request for information.

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SUMMARY: The CFPB, an independent agency, HHS, and the Treasury 
(collectively, the agencies), are soliciting comments from the public 
and interested parties on medical credit cards, loans, and other 
financial products used to pay for health care. The agencies seek to 
understand the prevalence, nature, and impact of these products, 
including disparities across different demographic groups. The agencies 
also seek to understand the effects these products may have on patients 
and on the health care system. In particular, the agencies seek comment 
on whether these products may allow health care providers to operate 
outside of a broad range of patient and consumer protections. The 
agencies also seek comment on whether these products may contribute to 
health care cost inflation, displace hospitals' provision of financial 
assistance, lead patients to pay inaccurate or inflated medical bills, 
increase the amount patients must pay due to financing costs, or 
otherwise harm patients' mental, physical, and financial well-being, 
including through downstream credit reporting and debt collection 
practices. In line with the agencies' work to lower health care costs 
and reduce the burden of medical debt, the agencies also seek comment 
on policy options to protect consumers from harm.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below by September 11, 2023.

ADDRESSES: Interested parties are encouraged to submit written comments 
to any and all agencies listed below. Comments submitted to the Federal 
eRulemaking Portal will be shared with all agencies for consideration. 
Comments should be directed to:
    CFPB: You may submit responsive information and other comments, 
identified by Docket No. CFPB-2023-0038, by any of the following 
methods:
     Federal eRulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
     Email: [email protected]. Include Docket No. 
CFPB-2023-0038 in the subject line of the message.
     Mail/Hand Delivery/Courier: Comment Intake--Request for 
Information Regarding Medical Payment Products, Consumer Financial 
Protection Bureau, 1700 G Street NW, Washington, DC 20552. Because 
paper mail in the Washington, DC area and at the Bureau is subject to 
delay, commenters are encouraged to submit comments electronically.
    HHS: You may submit responsive information and other comments, 
identified by Docket No. CMS-2023-0106, by any of the following 
methods:
    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: Docket No. CMS-2023-0106, 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: Docket No. CMS-
2023-0106, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 
21244-1850.
    Treasury: You may submit responsive information and other comments, 
identified by Docket No. TREAS-DO-2023-0008, by any of the following 
methods:
     Federal eRulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
    Instructions: The agencies encourage the early submission of 
comments. All submissions must include the document title and docket 
number. Please note the number of the topic on which you are commenting 
at the top of each response (you do not need to address all topics). In 
general, all comments received will be posted without change to https://www.regulations.gov. All comments, including attachments and other 
supporting materials, will become part of the public record and subject 
to public disclosure. Proprietary information or sensitive personal 
information, such as account numbers or Social Security numbers, or 
names of other individuals, should not be included. Comments will not 
be edited to remove any identifying or contact information.

FOR FURTHER INFORMATION CONTACT: 
    CFPB: Octavian Carare, Supervisory Economist, Consumer Financial 
Protection Bureau, at [email protected] or (202) 435-7700. If 
you require this document in an alternative electronic format, please 
contact [email protected].
    HHS: Czarina Biton, Centers for Medicare & Medicaid Services, at 
[email protected] or 301-276-1770.
    Treasury: Thomas West, Deputy Assistant Secretary, U.S. Department 
of the Treasury at [email protected] or 202-622-2000.

SUPPLEMENTARY INFORMATION: 

Table of Contents

I. Background:
    a. Overview
    b. The Medical Payment Product Market
    c. Patient Experience and Downstream Consequences
    d. Risk of Exacerbating Billing and Financial Assistance Issues
    e. Potential Distortion of Health Care Provider Incentives

[[Page 44282]]

    f. Potential for Consumer Harm
II. Request for Information
    a. General Questions
    Market-Level Inquiries
    Individual Inquiries
    b. CFPB-Specific Questions
    c. HHS-Specific Questions
    d. Treasury-Specific Questions

I. Background

a. Overview

    Many people have difficulty paying for medical care. Although 
insurance coverage has expanded over the last two decades and the 
uninsured rate has recently reached historic lows, the cost of medical 
care, and particularly the out-of-pocket cost for patients and 
families, has grown faster than inflation.\1\ For many patients, the 
financial challenges associated with paying for medical care are 
compounded by the complexities of health care coverage determinations 
as well as by medical billing and payment systems that can result in 
inaccuracies and errors that only increase the financial and 
psychological burden on patients.
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    \1\ Peterson-KFF, Shameek Rakshit, Emma Wager, Paul Hughes-
Cromwick, Cynthia Cox, and Krutika Amin, ``How does medical 
inflation compare to inflation in the rest of the economy?'' (March 
2023), available at https://www.healthsystemtracker.org/brief/how-does-medical-inflation-compare-to-inflation-in-the-rest-of-the-economy/.
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    Although patients have many options to pay for care, health care 
providers may encourage patients and their families to use commercial 
medical payment products, including medical credit cards and 
installment loans, to finance care.\2\ Health care providers may 
promote medical payment products because the use of these products 
allows providers to avoid the administrative burden of slow and complex 
insurance reimbursement, outsource servicing and collections costs, get 
paid faster, and receive payment from people who otherwise would not 
pay the full price for care.\3\ However, for patients, using these 
products can complicate insurance coverage, interfere with the 
availability of financial assistance, make it difficult to dispute 
inaccurate or inflated medical bills, and increase the total cost of 
care through interest and fees. It is also possible that some people 
who pay for care using medical payment products are charged higher 
prices for their care than they otherwise would have been asked to pay, 
such as gross charges (also known as chargemaster prices).\4\
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    \2\ CFPB, ``Medical Credit Cards and Financing Plans'' (May 
2023), available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
    \3\ Id. at 8.
    \4\ ``Gross charge'' and ``chargemaster'' here refer to the 
definitions provided in 45 CFR 180.20, namely, ``Chargemaster means 
the list of all individual items and services maintained by a 
hospital for which the hospital has established a charge,'' and 
``Gross charge means the charge for an individual item or service 
that is reflected on a hospital's chargemaster, absent any 
discounts.''
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    Patients may use risky and expensive commercial medical payment 
products rather than low- or no-cost alternatives because they do not 
know alternatives exist, they do not understand the risks and costs of 
medical payment products, or they feel pressured or coerced into 
signing up for these products.\5\ In some cases, medical payment 
products may allow patients to access care they would otherwise have to 
forgo. However, these payment products can also lead to patients paying 
more out of pocket if patients use medical payment products to pay 
bills that should have been covered by insurance or financial 
assistance, to pay inaccurate bills which they then have difficulty 
disputing post-payment, or to pay bills in full whose balances they 
would otherwise have been able to negotiate pre-payment.
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    \5\ Id. at 10.
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    Health care providers and financial companies may also use these 
payment products to attempt to avoid restrictions on credit reporting 
and debt collection practices that otherwise apply to medical debt, 
including restrictions imposed by national credit reporting companies 
and restrictions imposed by Federal law.\6\ Specifically, the three 
national credit reporting companies voluntarily do not report medical 
debt collections items with original balances under $500 or which are 
less than one year old, but they have not restricted the reporting of 
debt collections items reported with classification codes indicating 
that they are ``credit card'' or ``installment loan'' collections. 
Additionally, section 501(r) of the Internal Revenue Code (IRC) 
prohibits tax-exempt hospital organizations from engaging in 
extraordinary collection actions, including reporting the patient's 
debt to credit reporting companies or sending the patient's debt to a 
third-party debt collector, before the organization has made reasonable 
efforts to determine whether the individual is eligible for assistance 
under the hospital's financial assistance policy.\7\ However, the 
agencies believe that tax-exempt hospitals and the financial companies 
that partner with them may not be making reasonable efforts to 
determine whether an individual is eligible for financial assistance 
before offering the individual a medical payment product or taking 
extraordinary collection actions to attempt to collect an overdue 
medical payment product balance.
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    \6\ CFPB, ``Debt collectors re-evaluate medical debt furnishing 
in light of data integrity issues,'' available at https://www.consumerfinance.gov/about-us/blog/debt-collectors-re-evaluate-medical-debt-furnishing-in-light-of-data-integrity-issues/.
    \7\ Internal Revenue Service, ``Billing and Collections--Section 
501(r)(6),'' available at https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6.
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    In this Request for Information (RFI), CFPB, HHS, and Treasury seek 
comment on the prevalence, nature, and impact of medical payment 
products on consumers and on the health care system. The agencies also 
seek comment on policy options to address practices by health care 
providers, health insurance issuers, employer-sponsored health plans, 
and financial companies that result in consumers paying excess costs.
    This RFI builds upon recent work by CFPB, HHS, Treasury, and other 
Federal agencies to assist consumers with managing health care costs 
and medical bills, and to protect patients and consumers from paying 
inaccurate or inflated medical bills.\8\ That work includes CFPB 
research into the extent and impact of medical debt and the accuracy of 
those debts,\9\ as well as CFPB guidance to prevent unlawful medical 
debt collection and reporting.\10\ It also includes actions by HHS and 
other agencies to implement surprise

[[Page 44283]]

billing protections,\11\ enforce price transparency measures,\12\ lower 
health care costs,\13\ and increase access to affordable, quality 
health care.\14\ Additionally, it includes policy development by 
Treasury on surprise billing protections and on requirements that 
specifically apply to tax-exempt hospitals, including those relating to 
billing and collection, financial assistance policies, and community 
benefits.
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    \8\ The White House, ``FACT SHEET: New Data Show 8.2 Million 
Fewer Americans Struggling with Medical Debt Under the Biden-Harris 
Administration'' (Feb. 2023), https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/14/fact-sheet-new-data-show-8-2-million-fewer-americans-struggling-with-medical-debt-under-the-biden-harris-administration/, and The White House, ``FACT SHEET: The 
Biden Administration Announces New Actions to Lessen the Burden of 
Medical Debt and Increase Consumer Protection'' (Apr. 2022), 
available at https://www.whitehouse.gov/briefing-room/statements-releases/2022/04/11/fact-sheet-the-biden-administration-announces-new-actions-to-lessen-the-burden-of-medical-debt-and-increase-consumer-protection/.
    \9\ CFPB, ``Medical debt burden in the United States,'' 
available at https://www.consumerfinance.gov/data-research/research-reports/medical-debt-burden-in-the-united-states/; CFPB, ``Debt 
collectors re-evaluate medical debt furnishing in light of data 
integrity issues,'' available at https://www.consumerfinance.gov/about-us/blog/debt-collectors-re-evaluate-medical-debt-furnishing-in-light-of-data-integrity-issues/; and CFPB, ``Medical Billing and 
Collections Among Older Americans,'' available at https://www.consumerfinance.gov/data-research/research-reports/issue-spotlight-medical-billing-and-collections-among-older-americans/full-report/.
    \10\ CFPB ``Bulletin 2022-01: Medical Debt Collection and 
Consumer Reporting Requirements in Connection with the No Surprises 
Act,'' available at https://www.consumerfinance.gov/compliance/supervisory-guidance/cfpb-bulletin-2022-01-medical-debt-collection-consumer-reporting-requirements-in-connection-with-no-surprises-act/.
    \11\ See HHS, ``HHS Kicks Off New Year with New Protections from 
Surprise Medical Bills,'' available at https://www.hhs.gov/about/news/2022/01/03/hhs-kicks-off-new-year-with-new-protections-from-surprise-medical-bills.html.
    \12\ See CMS, ``Hospital Price Transparency Enforcement 
Updates,'' available at https://www.cms.gov/newsroom/fact-sheets/hospital-price-transparency-enforcement-updates.
    \13\ See CMS, ``Hospital Price Transparency Enforcement 
Updates,'' available at https://www.cms.gov/newsroom/fact-sheets/hospital-price-transparency-enforcement-updates.
    \14\ See The White House, ``Executive Order on Continuing to 
Strengthen Americans' Access to Affordable, Quality Health 
Coverage,'' available at https://www.whitehouse.gov/briefing-room/presidential-actions/2022/04/05/executive-order-on-continuing-to-strengthen-americans-access-to-affordable-quality-health-coverage/.
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    Patients' use of medical payment products occurs within the larger 
context of medical billing and collections as well as health insurance 
practices, and affects access to health care, implicating the 
jurisdictions of CFPB, HHS, and Treasury. Given these overlapping 
equities, the agencies are committed to working together to understand 
and address the harms medical payment products may cause, as part of 
their work more generally on health care costs, medical billing, and 
medical collections.

b. The Medical Payment Product Market

    Commercial medical payment products include medical credit cards 
and installment loans used to help patients cover the cost of medical 
treatments. Charges to these products are limited to medical 
procedures, items, or services at participating medical service 
providers, including primary and specialty care, labs and diagnostics, 
inpatient and outpatient services, dental, vision, and pharmacy 
care.\15\
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    \15\ Medical payment products may also include Buy Now Pay Later 
(BNPL) products, an emerging product category sometimes referred to 
as ``Care Now Pay Later.'' See, e.g., Stuart Condie, `` `Buy Now, 
Pay Later' Looks to Healthcare for Shot in the Arm,'' Wall Street 
Journal (July 22, 2022), available at https://www.wsj.com/articles/buy-now-pay-later-looks-to-healthcare-for-shot-in-the-arm-11658491200. Certain other payment methods that are marketed for use 
to cover medical costs do not restrict charges to medical items and 
services; the agencies are interested in hearing more about these 
products and their similarities to or differences from medical-only 
payment products.
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    Medical payment products are administered by financial services 
companies, who manage the billing and collections process for these 
products and earn revenue through interest and fees. Medical credit 
card companies include CareCredit, a subsidiary of Synchrony Financial; 
Wells Fargo; and Comenity, a subsidiary of Bread Financial. The medical 
installment loan market includes a large number of companies, among 
which some of the most prominent are AccessOne, Prosper, PayZen, 
Walnut, and Scratchpay.\16\ Many medical installment loan companies, 
including the five previously mentioned, are backed by private equity 
firms.\17\
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    \16\ The number of medical installment loan providers is much 
greater than the number of medical credit card lenders, and these 
products vary in many ways. Appendix A in ``Medical Credit Cards and 
Financing Plans'' includes a sample of installment loans and 
publicly available information on their terms and conditions. CFPB, 
``Medical Credit Cards and Financing Plans,'' at 18, available at 
https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
    \17\ See, e.g., KFF, ``How Banks and Private Equity Cash In When 
Patients Can't Pay Their Medical Bills'' (Nov. 2022), available at 
https://kffhealthnews.org/news/article/how-banks-and-private-equity-cash-in-when-patients-cant-pay-their-medical-bills/.
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    Medical payment products were once used primarily to pay for care 
not traditionally covered by health insurance plans, such as dental and 
vision care, fertility services, and cosmetic surgery. However, medical 
payment products are now also used to pay for a broader set of 
services, including emergency room visits and primary and specialty 
care. Available data, although limited, show significant growth in the 
medical payment product industry over the last several years. For 
example, CareCredit grew from 4.4 million cardholders and 177,000 
participating providers in 2013 to 11.7 million cardholders and over 
250,000 participating health care providers in 2023.\18\ Available data 
also suggest that medical payment products often have significantly 
higher interest rates than general purpose credit products; a recent 
CFPB report found that the typical annual percentage rate (APR) for 
medical credit cards was 27 percent, compared to a mean APR of 16 
percent for general purpose credit cards.\19\ Patients who use medical 
payment products may additionally find themselves facing high fees, 
deferred interest charges, and other adverse financial impacts.\20\ 
Additionally, as with other credit cards and installment loans, 
applying for and opening a medical payment product account may have 
negative implications for consumers' credit scores and access to credit 
through factors like hard credit checks, increased credit line 
utilization, decreased average account age, or eventual account 
closure.
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    \18\ This number, as publicized by CareCredit, includes also 
veterinary service providers and cardholders that use their card to 
finance veterinary care. CFPB, ``Medical Credit Cards and Financing 
Plans'' at 7, available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
    \19\ CFPB, ``Medical Credit Cards and Financing Plans,'' 
available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
    \20\ CFPB, ``Medical Credit Cards and Financing Plans,'' 
available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
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c. Patient Experience and Downstream Consequences

    The agencies seek additional information regarding the patient 
experience with medical payment products, including potential issues 
with the marketing, application, and enrollment processes as well as 
the impacts these products have on patients' financial, physical, and 
mental health.
    In general, coupling the sale of financial products to consumers 
with the provision of medical care may create consumer harm. In some 
cases, patients who trust their health care providers and their staff 
to give expert health care advice may place similar trust in the 
financing products offered by those providers and their staff. This may 
influence patients to sign up for products that are not in their best 
financial interest, especially when seeking or receiving medical care, 
a time when patients may be particularly vulnerable.\21\ Some patients 
have told the CFPB that they felt pressured to make quick financial 
decisions in a health care provider's office while under physical and 
emotional stress. Additionally, health care provider staff may not have 
the information, or the expertise needed to answer patients' questions 
about the terms and conditions of the financial products they offer. 
Staff may fail to inform patients of alternative payment options, 
including financial assistance.\22\ Staff
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    \21\ Jim Hawkins, ``Doctors as Bankers: Evidence from Fertility 
Markets'' Tulane Law Review (July 2010), available at https://www.tulanelawreview.org/pub/volume84/issue4/doctors-as-bankers.
    \22\ CFPB, ``Complaint Bulletin,'' available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf; and CFPB, ``Medical Credit Cards and 
Financing Plans'' at 8, available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.

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might also fail to provide information about the potential insurance 
coverage implications of using a medical payment product, or may 
encourage use of medical payment products instead of assisting the 
patient with filing an insurance claim. The CFPB has also received 
reports of some patients--particularly patients with limited English 
proficiency--allegedly being signed up for medical payment products 
without their knowledge or consent.
    Given these risks, the agencies seek additional information on 
medical payment product marketing, application, and enrollment 
processes, including how and when patients are offered these products, 
what information patients are given about these products, and how 
patients make decisions about utilizing these products. The agencies 
are interested in how promotion of these products may interfere with 
patients' health insurance coverage, undermine the provision of 
financial assistance, and reduce the availability and utilization of 
traditional provider-offered payment plans. The agencies are also 
interested in providers' and financial companies' disclosure practices 
and the information that is shared with patients about these products. 
Additionally, the agencies are interested in patients' experiences with 
medical payment products, including their overall satisfaction or 
dissatisfaction with these products as well as information on how these 
products were marketed to them, whether they understood the terms and 
conditions of the products, whether they felt pressured into signing 
up, or whether they were signed up for a medical payment product 
without their knowledge or consent.
    Secondly, the agencies seek to understand the impacts of these 
products on patients' financial health, including through high interest 
rates and fees, credit scoring or other scoring products, credit 
reporting practices, and debt collection practices. Many medical 
payment products charge interest and fees, including deferred interest, 
which may significantly increase the amount patients owe for their 
care.\23\ Patients with lower credit scores may be offered less 
favorable interest rates and terms, including shorter billing cycles 
(less than 30 days) that may increase the odds that these patients will 
incur late fees. Patients with lower credit scores may also be offered 
shorter deferred interest periods, increasing the likelihood that these 
patients will incur interest. Additionally, some financial services 
companies offer health care scoring products designed for health care 
providers, such as financial clearance scores and propensity-to-pay 
scores, which can be used to restrict access to care and promote 
payment products rather than financial assistance for those 
eligible.\24\ In some cases, patients with low financial clearance 
scores may be denied care unless they can pay up front, increasing the 
pressure on these patients to sign up for medical payment products. In 
other cases, patients whose predicted income and household size would 
qualify them for financial assistance, but who have a higher predicted 
propensity to pay, are channeled to medical payment products instead of 
being offered financial assistance.
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    \23\ Many medical payment products offer complex deferred 
interest promotions, which consumers often do not understand fully, 
and which can significantly increase the cost of their care if they 
do not pay in full during the promotional period. About 1 in 5 
consumers who use a deferred interest product to pay for care will 
ultimately pay interest. Borrowers with subprime credit scores are 
more likely to pay interest, perhaps in part because they are 
generally given less time to pay in full before being charged 
interest. CFPB, ``Medical Credit Cards and Financing Plans'' at 13, 
available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
    \24\ See, e.g., Experian, ``Patient Financial Clearance,'' 
https://www.experian.com/healthcare/products/payment-tools/patient-collections-and-financial-clearance; TransUnion, ``TransUnion 
Healthcare and VisitPay: A Patient Financial Engagement Solution,'' 
https://www.transunion.com/resources/transunion/doc/healthcare/transunion-healthcare-and-visitpay-a-patient-financial-engagement-solution-aite-brief.pdf.
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    Since medical credit cards have unique features such as shorter 
deferred interest periods and shorter billing cycles compared to other 
lines of credit, those with medical payment products may be at 
heightened risk of being sent to collections and reported to credit 
reporting companies. When past-due medical payment product balances are 
reported to credit reporting companies, this can lower patients' credit 
scores, even though medical debts generally are less predictive of 
creditworthiness than other debts.\25\ Lower credit scores can make it 
harder for consumers to get a loan, rent or buy a home, or find a 
job.\26\ Medical credit card or loan collections may be reported to 
consumer reporting agencies even when other medical bills could not 
appear on consumer reports, such as because of the restrictions on 
extraordinary collections actions placed by Congress \27\ or the 
national credit reporting companies' voluntary decision not to report 
medical collections that are paid, under $500, or less than a year 
old.\28\ Moreover, the incidence of referral to collections may be 
increased if patients paying for care with medical payment products are 
charged higher prices, if the costs of patients' medical services are 
inflated by interest and fees, or if paying via a medical payment 
product leads to the failure to file a timely and accurate insurance 
claim. Patients may also be sued for alleged medical payment product 
debts, which can lead to financial consequences like wage garnishment, 
bank attachments, seizure of personal property, and liens against 
patients' homes. Many people file bankruptcy in order to resolve large 
outstanding medical bills; \29\ it is possible that medical payment 
products contribute disproportionately to bankruptcy filings by people 
facing significant health challenges. Given these potential financial 
health impacts, the agencies are interested in information on the 
interest charges, default rates, credit reporting practices, and 
collections practices associated with medical payment products.
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    \25\ Kenneth P. Brevoort & Michelle Kambara, ``Data point: 
Medical debt and credit scores'' (May 2014), available at https://files.consumerfinance.gov/f/201405_cfpb_report_data-point_medical-debt-credit-scores.pdf.
    \26\ Alyssa Brown & Eric Wilson, ``Data Point: Consumer Credit 
and the Removal of Medical Collections from Credit Reports'' (Apr. 
2023), available at https://files.consumerfinance.gov/f/documents/cfpb_consumer-credit-removal-medical-collections-from-credit-reports_2023-04.pdf.
    \27\ Internal Revenue Service, ``Billing and Collections--
Section 501(r)(6),'' available at https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6.
    \28\ The three national credit reporting companies forbid credit 
reporting of medical debt collections items with original balances 
under $500 or which are less than one year old, but these 
restrictions do not apply to debt collections items reported with 
classification codes indicating that they are ``credit card'' or 
``installment loan'' collections. See CFPB, ``Have medical debt? 
Anything already paid or under $500 should no longer be on your 
credit report,'' available at https://www.consumerfinance.gov/about-us/blog/medical-debt-anything-already-paid-or-under-500-should-no-longer-be-on-your-credit-report/.
    \29\ David Himmelstein et al., ``Medical Bankruptcy: Still 
Common Despite the Affordable Care Act,'' American Journal of Public 
Health (Mar. 2019), https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2018.304901.
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    Thirdly, the agencies seek to understand the impacts of these 
products on patients' physical and mental health. Studies show that 
people often delay or avoid medical care out of concern about high 
costs or medical debt or because they believe they will be turned away 
due to their unpaid medical bills.\30\ Fifteen percent of adults

[[Page 44285]]

with medical debt say they have been denied health care because of 
their unpaid medical bills.\31\ To the extent that medical payment 
products contribute to higher health care costs and medical debts, 
these products may increase health care denial, delay, and avoidance, 
contributing to worse health outcomes and higher eventual health care 
costs due to forgone preventive and early intervention services. Higher 
costs and increased debt can also increase stress on consumers, 
contributing to negative physical and mental health outcomes.\32\ Given 
the risks to patients' health, the agencies seek comment on medical 
payment products' contribution to care avoidance and their impact on 
consumers' physical and mental health. The agencies are also interested 
in understanding if and when health care providers may deny or alter 
patients' care if they refuse to sign up for or fall behind on payments 
for a medical payment product.
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    \30\ See, e.g., Alyce Adams et al., ``The Impact of Financial 
Assistance Programs on Health Care Utilization: Evidence from Kaiser 
Permanente,'' American Economic Review: Insights, (Sept. 2022), 
available at https://www.aeaweb.org/articles?id=10.1257/aeri.20210515; Audrey Kearney et al., ``Americans' Challenges with 
Health Care Costs,'' KFF (July 14, 2021), https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/.
    \31\ Lunna Lopes et al., ``Health Care Debt in the U.S.: The 
Broad Consequences Of Medical And Dental Bills,'' KFF (June 16, 
2022), available at https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/.
    \32\ CFPB, ``Medical debt burden in the United States,'' at 32-
35, available at https://www.consumerfinance.gov/data-research/research-reports/medical-debt-burden-in-the-united-states/.
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    The agencies welcome comment on the above and on medical payment 
products' broader impacts on consumers' financial wellness, health care 
access, and physical and mental health.

d. Risk of Exacerbating Billing and Financial Assistance Issues

    Medical credit cards and loans may exacerbate existing issues in 
health care billing and collections by making it more difficult to 
resolve billing inaccuracies and allowing certain patients to be 
upcharged for services. For example, uninsured and self-pay 
patients,\33\ as well as patients receiving care from out-of-network 
providers,\34\ are often charged higher prices than those negotiated by 
health insurance issuers and group health plans for the same care 
furnished by an in-network provider \35\ (provided these patients are 
not determined eligible for financial assistance by a tax-exempt 
hospital).\36\ The availability of medical payment products may enable 
health care providers to charge higher prices to uninsured, self-pay, 
or out-of-network patients who would otherwise be unable to pay such 
prices and might instead seek more affordable care. In some cases, 
health care providers might offer medical payment products to uninsured 
patients instead of helping these patients determine their eligibility 
for health insurance coverage through Medicaid, Medicare, or subsidized 
Marketplace plans. Out-of-network health care providers might also 
offer medical payment products to patients instead of referring those 
patients to an in-network provider.
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    \33\ ``Self-pay patients'' here refers to the definition 
provided in 45 CFR 149.610(a)(2)(xiii)(B), which defines a self-pay 
individual as ``an individual who has benefits for such item or 
service under a group health plan, or individual or group health 
insurance coverage offered by a health insurance issuer, or a health 
benefits plan under chapter 89 of title 5, United States Code but 
who does not seek to have a claim for such item or service submitted 
to such plan or coverage.''
    \34\ A provider network is a list of the doctors, other health 
care providers, and hospitals that a plan contracts with to provide 
medical care to its members. These providers are called ``network 
providers'' or ``in-network providers.'' A provider that isn't 
contracted with the plan is called an ``out-of-network provider.'' 
CMS, ``What You Should Know About Provider Networks,'' available at 
https://marketplace.cms.gov/outreach-and-education/what-you-should-know-provider-networks.pdf.
    \35\ See Gerard Anderson, ``From `Soak the Rich' To `Soak the 
Poor': Recent Trends In Hospital Pricing'' (June 2007), Health 
Affairs, available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.26.3.780. See also Ge Bai, & Gerard F. Anderson, 
``US Hospitals Are Still Using Chargemaster Markups to Maximize 
Revenues'' (Sept. 2016), Health Affairs, available at https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2016.0093.
    \36\ In the case of individuals who receive care at a tax-exempt 
hospital who are determined eligible for financial assistance under 
the hospital's financial assistance policy, section 501(r)(5) 
prohibits tax-exempt hospitals from using gross charges and requires 
them to limit amounts charged for emergency or other medically 
necessary care to not more than the amounts generally billed to 
individuals who have insurance covering such care. Internal Revenue 
Service, ``Limitation on Charges--Section 501(r)(5),'' available at 
https://www.irs.gov/charities-non-profits/limitation-on-charges-section-501r5.
---------------------------------------------------------------------------

    Promotion of medical payment products may also undermine hospitals' 
provision of financial assistance. Section 501(r) of the Internal 
Revenue Code, which resulted from section 9007(a) of the Affordable 
Care Act, requires tax-exempt hospitals to establish a financial 
assistance policy for low-income patients, and many non-tax-exempt 
hospitals also voluntarily offer financial assistance to patients who 
meet criteria established by these hospitals. However, studies show 
that, in practice, many patients who are likely eligible for financial 
assistance under their hospitals' policies do not receive free or 
discounted care.\37\ In some instances, patients eligible for financial 
assistance are instead being steered to medical payment products, which 
are more profitable for providers.\38\ One way in which these products 
may be advantageous to health care providers, particularly tax-exempt 
hospitals, is by using these products in support of their non-profit 
status. For example, one medical installment loan company advertises to 
hospitals that its interest-charging loan product is a ``community 
benefit that makes care affordable'' and ``supports your organization's 
compliance with IRS regulation 501(r).'' \39\
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    \37\ See, e.g., Octavian Carare, et al., ``Exploring the 
connection between financial assistance for medical care and medical 
collections'' (Aug. 2022), CFPB, https://www.consumerfinance.gov/about-us/blog/exploring-connection-between-financial-assistance-for-medical-care-and-medical-collections/.
    \38\ See, e.g., Washington State Office of the Attorney General, 
``AG Ferguson files lawsuit against Swedish, other Providence-
affiliated hospitals, for failing to make charity care accessible to 
thousands of Washingtonians,'' available at https://www.atg.wa.gov/news/news-releases/ag-ferguson-files-lawsuit-against-swedish-other-providence-affiliated-hospitals; State of California Department of 
Justice, ``Attorney General Bonta Issues Consumer Alert Following 
Reports of Hospitals Failing to Inform Patients of Options for Free 
or Reduced-Price Medical Care,'' available at https://oag.ca.gov/news/press-releases/attorney-general-bonta-issues-consumer-alert-following-reports-hospitals-failing; and The Office of Minnesota 
Attorney General Keith Ellison, ``Attorney General Ellison secures 
relief from unfair bill collection for Hutchison Hospital 
patients,'' available at https://www.ag.state.mn.us/Office/Communications/2020/10/29_HutchinsonHealth.asp.
    \39\ ClearBalance HealthCare, ``Experience to Solve Patient 
Pay,'' https://www.bokfinancial.com/-/media/Files/PDF/Commercial/Healthcare/CBHC_Overview.ashx.
---------------------------------------------------------------------------

    Finally, utilizing medical payment products may undermine patients' 
medical billing rights, including their No Surprises Act rights to 
dispute surprise bills and their Affordable Care Act rights to 
insurance appeals and reviews. Consumers report that errors in medical 
bills are common; among those with medical debt, more than four in ten 
say they received an inaccurate bill, and nearly seven in ten say they 
were asked to pay a bill that should have been covered by 
insurance.\40\ However, some consumers report being told that they had 
no right to dispute inaccurate bills placed on a medical payment 
product, even if they discovered after enrolling in the payment product 
that they were billed in error or that their bill should have been 
covered by insurance--or even if they never received the service at 
all.
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    \40\ KFF, ``Healthcare Debt in the US: The Broad Consequences of 
Medical and Dental Bills,'' available at https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/.
---------------------------------------------------------------------------

e. Potential Distortion of Health Care Provider Incentives

    Several factors may incentivize health care providers to promote 
medical payment products even when these products are not in patients' 
best

[[Page 44286]]

financial interest. First, changes to private health care coverage may 
incentivize providers to promote medical payment products. For example, 
providers may turn to medical payment products in response to growing 
deductibles, copayments, and coinsurance charged by private group 
health plans and health insurance issuers, which many patients cannot 
afford to pay in cash up front.\41\ Slow insurance reimbursement and 
frequent insurance denials, downcoding,\42\ or appeals may also make 
medical payment products an attractive alternative to insurance 
payment. Additionally, out-of-network providers may promote medical 
payment products to patients because group health plans and health 
insurance issuers may not directly reimburse out-of-network providers; 
having patients pay out-of-network providers up front using a medical 
payment product effectively transfers the risk of non-reimbursement or 
slow reimbursement from the out-of-network provider to the patient.
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    \41\ Fifty percent of U.S. adults say they would be unable to 
pay a $500 medical bill without going into debt; the average 
deductible for single person health coverage was $2,004 in 2021, up 
from $1,273 in 2013. KFF, ``Average Annual Deductible per Enrolled 
Employee in Employer-Based Health Insurance for Single and Family 
Coverage,'' available at https://www.kff.org/other/state-indicator/average-annual-deductible-per-enrolled-employee-in-employer-based-health-insurance-for-single-and-family-coverage/; and KFF, ``Health 
Care Debt In The U.S.: The Broad Consequences Of Medical And Dental 
Bills,'' available at https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/. Regarding the marketing of medical 
payment products to providers to address these rising health care 
costs, see Allison J. Zimmon, ``Rx for Costly Credit: Deferred 
Interest Medical Credit Cards Do More Harm than Good,'' 35 B.C.J. L 
& Soc. Just. 319 (2015).
    \42\ Downcoding here refers to the practice of a plan or issuer 
reviewing a claim submitted by a health care provider or facility 
and altering the service code or modifier to another service code or 
modifier that the plan or issuer determines to be more appropriate, 
resulting in a lower reimbursement.
---------------------------------------------------------------------------

    Secondly, health care providers may be incentivized to promote 
medical credit cards and loans because these products result in faster 
payment, lower administrative costs, and more revenue overall for the 
health care provider compared to alternatives like financial assistance 
or provider-administered payment plans. In their promotional materials, 
financial companies offering medical payment products emphasize their 
products' potential to deliver payments within a few days, minimize 
financial risk, and reduce the administrative burden associated with 
collecting debts or negotiating with group health plans or health 
insurance issuers. Traditionally, when a patient cannot pay their bill 
upfront, the health care provider would take on the costs of 
administering a payment plan, mailing statements, processing accounts 
receivable, handling disputes, and engaging debt collectors. When a 
patient instead pays for medical services out-of-pocket or via credit 
card or installment loan, the health care provider avoids many of these 
costs and generally receives payment immediately or within days. If the 
patient does not use their health insurance coverage, the health care 
provider may also be able to charge them higher rates, such as gross 
charges or a cash rate rather than a charge negotiated between the 
provider and third-party payers.\43\ Additionally, easy access to 
credit may encourage patients to consume more health care from 
providers who offer medical credit products, resulting in more overall 
revenue for these providers. Indeed, some financial companies 
explicitly advertise that their products will help providers ``upsell'' 
patients on more expensive and potentially unnecessary care.\44\
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    \43\ Here, ``gross charges,'' ``cash rates,'' and ``charges 
negotiated between the provider and third-party payers'' refers to 
the definitions of those terms provided in section 2718(e) of the 
Public Health Service Act (Hospital Price Transparency).
    \44\ For example, ``Cherry can be used for consumers that want a 
product/service but don't want to pay the full amount upfront today. 
This gives you, the business owner, the power to upsell and increase 
your sales.'' CFPB, ``Medical Credit Cards and Financing Plans,'' at 
9 n.29, available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
---------------------------------------------------------------------------

    Certain financial companies offer additional incentives to health 
care providers to promote medical payment products. In some cases, this 
may include a share of the revenue from these products. For example, 
one medical installment loan company advertises that providers who 
offer the product will ``share in interest revenue collected.'' \45\ 
Other medical payment product companies offer lower processing or 
management fees to providers who enroll more consumers--giving those 
providers an incentive to enroll as many patients as possible.\46\ 
Where financial companies incentivize the referral or recommendation of 
business reimbursable under Federal health care programs, it is 
possible that these practices may implicate Federal laws or regulations 
including the Federal anti-kickback statute, 42 U.S.C. 1320a-7b(b) and 
its implementing regulations, which provides for criminal penalties for 
whoever knowingly and willfully offers, pays, solicits, or receives 
anything of value to induce or reward the referral, recommendation, or 
arranging for the referral or recommendation of business reimbursable 
under Federal health care programs.
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    \45\ Choice Payment Services, ``ChoicePays+,'' available at 
https://choicepays.com/choicepays/.
    \46\ CFPB, ``Medical Credit Cards and Financing Plans,'' at 10, 
available at https://files.consumerfinance.gov/f/documents/cfpb_medical-credit-cards-and-financing-plans_2023-05.pdf.
---------------------------------------------------------------------------

    Some medical payment product companies advertise that their 
products allow health care providers, debt collectors, and credit 
reporting companies to attempt to avoid restrictions on extraordinary 
collection actions and on credit reporting of alleged bills. Under IRC 
501(r) and the regulations thereunder, tax-exempt hospital 
organizations must make reasonable efforts to determine whether an 
individual is eligible for assistance under the hospital organization's 
financial assistance plan before engaging in extraordinary collection 
actions against that individual, such as credit reporting, third-party 
collections, and debt sale (except under certain special 
conditions).\47\ However, the agencies believe financial companies may 
be engaging in credit reporting, debt sales, and other extraordinary 
collection actions on debts arising from an individual's care at a tax-
exempt hospital without first making reasonable efforts to determine 
that individual's financial assistance eligibility.
---------------------------------------------------------------------------

    \47\ Internal Revenue Service, ``Billing and Collections--
Section 501(r)(6),'' available at https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6.
---------------------------------------------------------------------------

    Additionally, the three national credit reporting companies 
voluntarily refrain from reporting medical collections items that are 
less than $500 or under one year old to the credit reporting companies. 
However, these restrictions do not extend to debts reported with 
classification codes indicating that they are ``credit card'' or 
``installment loan'' collections, even if the credit card or 
installment loan was used to pay medical bills.

f. Potential for Consumer Harm

    The growing prevalence of medical payment products creates 
significant potential for consumer harm. Patients are often offered and 
enroll in medical payment products at a health care provider's 
location, meaning that health care providers and their staff are 
frequently the people who are directly marketing these products to 
their patients. People trust health care providers and their staff to 
provide sound and effective treatment options. When their health care 
providers and their staff also provide information or

[[Page 44287]]

advice on payment options, patients might assume the health care 
provider or staff member is being transparent about the full set of 
options and not being driven by their own financial incentives.\48\ 
Patients might also extend their trust in their health care providers 
to a referred financial services company. Additionally, financial 
decisions by patients in health care settings are compromised by the 
stress inherent in managing an illness or injury.
---------------------------------------------------------------------------

    \48\ Office of Inspector General (OIG) Advisory Opinion 02-12 at 
11 (``[H]ealth care providers are in a position of trust and may 
exert undue influence when recommending health care related items or 
services, particularly to their own patients.'').
---------------------------------------------------------------------------

    Incomplete, incorrect, or misleading information about the cost of 
their treatment, financing options offered, and the availability of 
low- or no-cost financing alternatives can also compromise financial 
decisions made at the point of care. As a result, patients may feel 
pressured or coerced into signing up for medical payment products that 
cause downstream financial or health problems, including through debt 
collection or credit reporting of medical bills that might have 
inaccurate information. Patients might also avoid or delay care if they 
are unaware of the availability of financial assistance and other 
affordable financing options or are concerned about their ability to 
pay their health care bills.

II. Request for Information

    In this RFI, the CFPB, HHS, and Treasury seek data and comments on 
the scope, prevalence, terms, and impacts of medical payment products, 
including medical credit cards and loans. The agencies are also 
interested in the downstream consequences of these products and in 
potential actions to address any harms caused by these products.
    To better understand the medical payment product market, the 
agencies seek data and comments on the interest and fee costs of these 
products (including both interest rates and total accrued interest), 
the application and approval process for these products, and trends of 
medical payment product use. The agencies also seek information as to 
the total outstanding consumer debt on medical credit cards, medical 
installment loans, and other medical payment products. Data regarding 
the characteristics and demographics of medical payment products users 
is also welcome, such as whether users are insured or uninsured, 
whether certain populations or income groups are more likely to use 
these products, and whether use is concentrated in certain geographies 
or for patients seeking particular kinds of care. The agencies also 
seek to better understand the level of concentration in the medical 
payment product market, the ownership of medical payment product 
companies (including ownership by health care providers, health 
insurance issuers, or private equity firms), and the implications of 
these factors for competition and consumer choice. To that end, the 
agencies seek specific information on the types of financial entities 
that offer medical credit cards and loans.
    The agencies seek to understand to what extent medical credit cards 
and loans may hamper financial assistance and access to benefits, and 
any options for regulators to reduce such barriers. The agencies also 
seek to understand the extent to which health care providers, including 
tax-exempt hospitals, screen patients for public or private insurance 
eligibility, financial assistance eligibility, or other benefits before 
offering them medical credit cards or loans. The agencies additionally 
seek comment on how frequently patients discover billing errors after 
signing up for a medical payment product, the main sources of billing 
errors, and how paying medical bills via a medical payment product 
affects patients' ability to dispute those bills. The agencies seek 
comment on how to ensure that patients retain their rights to challenge 
inaccurate bills regardless of payment method.
    The agencies also seek comment on incentives offered by financial 
companies to health care providers for their promotion of medical 
payment products, including revenue-sharing and other incentives. The 
agencies are also interested in any training or other support that 
medical payment product companies offer to providers. The agencies are 
interested in whether such incentives or support might implicate the 
Federal anti-kickback statute or other laws or regulations. The 
agencies also seek information regarding how plans and issuers' billing 
and reimbursement practices affect health care providers' decisions to 
offer and promote medical payment products.
    The agencies seek additional information on the prices or versions 
of standard charges offered to patients who use these products, and 
whether these charges are adequately disclosed in accordance with 
hospital price transparency requirements and No Surprises Act good 
faith estimate requirements. The agencies seek information on whether 
medical payment product companies are operating outside of protections 
against credit reporting of medical collections items and against 
extraordinary collection actions by tax-exempt hospitals. Finally, the 
agencies seek to better understand how notice and consent requirements 
for post-stabilization and non-emergency health care items or services 
under the No Surprises Act intersect with providers' promotion of 
medical credit cards and loans to out-of-network patients.
    In general, the agencies welcome any information that allows us to 
better understand the impact of medical payment products on patients' 
physical, mental, and financial health. The agencies also welcome 
suggestions of actions Federal agencies could take to address harms 
caused by medical payment products and related issues connected to 
medical billing and collections or medical debt more generally. The 
agencies welcome comment on these areas, including comments in response 
to any of the following specific questions:

a. General Questions

Market-Level Inquiries
    1. What are the benefits, costs, and risks of medical payment 
products for consumers, health care providers, and companies offering 
these products?
    2. What are the terms of medical payment products, including 
interest rates and fees?
    3. How much debt do consumers carry on medical credit cards and 
loans in total, and what is the average individual debt level?
    4. How concentrated is the medical payment product market, and what 
role do private equity firms play in this market?
    5. Are there specific populations (e.g., race, socioeconomic 
status, gender identity, sexual orientation, age, language, etc.) or 
geographic regions that experience disproportionately higher 
utilization of medical payment products?
    6. What are the health equity impacts of medical payment products 
and related billing and collection policies and practices?
    i. Do medical payment products affect members of specific 
underserved communities differently, including members of Tribal 
communities and geographically isolated communities?
    ii. Do certain products or policies present opportunities to better 
serve members of underserved communities?
    7. Patients can pay for care in many different ways, such as by 
medical credit card or loan, general purpose credit card, insurance, or 
through a zero-interest payment plan. What are

[[Page 44288]]

the costs and benefits for health care providers of offering each of 
these methods? Are there situations where one method of payment is more 
advantageous than another?
    8. What incentives do financial services companies offer health 
care providers, including revenue-sharing or other financial or non-
financial incentives?
    9. How do medical payment products and health insurance coverage 
interact? Do group health plan or health insurance issuer practices 
contribute to uptake of medical payment products by patients and 
providers?
    i. How many days do providers typically have to wait to be paid by 
plans or issuers versus by medical payment product companies or general 
purpose credit card companies? What factors, such as administrative 
requirements or clinical reviews, contribute to any differential 
resolution timelines?
    ii. Does a patient's use of a medical payment product exempt them 
from certain consumer protections, provider requirements, or group 
health plan or health insurance issuer requirements? Are different 
types of health coverage treated differently?
    10. Does health care provider organizational structure, including 
ownership by private equity, affect providers' decisions to offer and 
promote these products?
    11. What are some best practices for health care providers who 
offer medical payment products in avoiding adverse financial and health 
impacts for patients?
    i. Are there specific tactics or practices that are well tailored 
and adapted for use by health care professionals in and serving 
underserved communities, including Tribal communities and 
geographically isolated communities?
    ii. What actions should the agencies take to develop and encourage 
uptake of these established best practices?
    iii. Are there examples of actions or best practices at the State 
or local level to which the Federal government should look?
    12. To what extent are patients using medical payment products to 
pay bills that are incorrect, or that could be covered or defrayed by 
lower-cost alternatives?
    i. What billing errors may patients commonly encounter?
    ii. How does using a medical payment product affect patients' 
rights to dispute incorrect bills?
    iii. Are certain groups of patients, such as members of specific 
underserved communities, more likely to experience medical billing 
errors or issues resolving disputes over bills paid using medical 
payment products?
    13. What actions should agencies consider taking to better 
understand the effects of medical payment products on consumers and the 
health care industry, educate consumers and providers about the risks 
of these products, and collect complaints?
    i. What are some sources of data on medical payment products? What 
additional data are needed to understand the impact of medical payment 
products on patients and the health care industry?
    ii. What data collection, data analysis, and research actions 
should agencies take?
    iii. Are there different or other actions that agencies should 
consider for underserved communities, including Tribal communities and 
geographically isolated communities?
    iv. What types of consumer complaints have States and localities 
received?
    14. Where medical payment products are causing harm, what are some 
specific levers for regulatory oversight and enforcement by Federal 
agencies that regulate financial products or health care providers?
    i. Are there specific areas for Federal enforcement actions?
    ii. Are there examples of regulation or enforcement at the State or 
local level to which the Federal government should look?
    iii. What complementary legislative actions are worth exploring? 
Where may additional statutory authority be needed?
Individual Inquiries
    1. Have medical payment products ever been marketed to you, 
including by your health care provider? If so, please describe your 
experience and how the products were marketed to you. Were other 
options, such as financial assistance, marketed or explained at the 
same time?
    2. If you have used a medical credit card or loan to pay for your 
care, what was your experience with the product?
    a. What benefits or harms did you experience?
    b. Was your health affected by your use of a medical credit card or 
loan?
    c. How much did interest and fee charges add to the cost of your 
care?
    d. How did using a medical credit card or loan affect your credit 
score and your ability to access credit?
    e. Would you use a medical credit card or loan to cover medical 
expenses again? Why or why not?
    3. Have you ever tried to dispute a medical bill you paid using a 
medical credit card or loan? If so, please describe your experience.
    4. Have you ever had an overdue bill on a medical credit card or 
loan sent to collections? How quickly was the bill sent to collections? 
Did your experience with collections affect your credit score, your 
access to medical care, or your health?
    5. Have you ever felt pressured to pay for care using a medical 
payment product or general purpose credit card when you believed that 
was not in your best interest? If so, please describe your experience.
    6. Have you ever used or been pressured to use a medical credit 
card or loan to pay a bill that you believe should have been covered by 
your health insurance? If so, please describe your experience.
    7. Have you ever used or been pressured to use a medical credit 
card or loan to pay a bill that you believe should have been covered by 
your health care provider's financial assistance policy? If so, please 
describe your experience.
    8. Has your knowledge about the availability of medical credit 
cards or loans led you to believe that health insurance might not be 
necessary, or not acquire health insurance?

b. CFPB-Specific Questions

    The CFPB implements and enforces Federal consumer financial law, 
including the Fair Credit Reporting Act, the Fair Debt Collection 
Practices Act, the Equal Credit Opportunity Act, and the Consumer 
Financial Protection Act's prohibition on unfair, deceptive, or abusive 
acts or practices in connection with the offering or provision of 
consumer financial products or services. As such, the CFPB seeks to 
better understand consumer financial issues raised by medical payment 
products, including the credit practices of medical payment product 
companies as well as the debt collection and credit reporting practices 
utilized by both health care providers and medical payment product 
companies. The CFPB welcomes comment on these areas, including comments 
in response to any of the following specific questions:
    1. What actions should the CFPB consider taking to address 
problematic practices related to medical credit cards or loans, 
including debt collection and credit reporting practices?
    2. How do firms offering medical financial products typically 
market to providers?
    3. How do creditors and their affiliates underwrite loans to 
patients? What specific factors (e.g., age, type of

[[Page 44289]]

medical procedure, credit score, etc.) are considered in underwriting?
    4. Do consumers understand the risks of paying medical bills via a 
medical credit card, installment loan, or other commercial payment 
product, including lowered ability to negotiate their bill with their 
provider?
    5. To what extent are alleged debts placed on medical credit cards 
and loans sent to debt collectors? How do medical payment product 
companies' debt collection practices differ from those of health care 
providers, and are any issuer or provider debt collection practices 
posing risks to consumers?
    6. How can the CFPB use its authorities to ensure people with 
medical bills in collections, including medical payment product debt, 
are screened for eligibility for financial assistance and other 
benefits?
    7. How are health care providers and financial companies using 
credit or ``propensity to pay'' scores to determine patients' 
eligibility for financial assistance or medical payment products? What 
are the implications for compliance with the Fair Credit Reporting Act 
or other CFPB authorities?
    8. When hospitals write off a patient's debt as uncollectible or 
``bad debt'' and cease attempts to collect, do they notify patients 
that collection attempts will cease? Would patients benefit from such 
notifications, and would such notifications reduce hospital revenue?

c. HHS-Specific Questions

    The Department of Health and Human Services shares jurisdiction 
with the Departments of Treasury and Labor over key health care 
consumer protections related to health coverage, including those 
enacted by the Affordable Care Act and the No Surprises Act. HHS is 
also responsible for regulation and oversight of Medicare, Medicaid and 
the Children's Health Insurance Program, and the Affordable Care Act 
Marketplaces, and shares responsibility for enforcement of Federal 
health care fraud and abuse laws, including the Federal anti-kickback 
statute. HHS works to enhance the health and well-being of all 
Americans by providing for effective health and human services and by 
understanding and addressing the barriers patients experience in 
accessing health care. HHS also includes the Indian Health Service 
(IHS), which administers and oversees health and human services 
programs for American Indians and Alaska Natives.
    HHS seeks to better understand how medical payment products affect 
access to care and intersect with health care coverage, including 
Medicare, Medicaid, and the Children's Health Insurance Program, group 
and individual health insurance coverage (including Marketplace plans 
and employer-sponsored coverage), and non-comprehensive coverage 
products. HHS also seeks specific comments from all Indian Health Care 
Providers, including Indian Tribal Governments, Tribal Organizations, 
and Urban Indian Organizations about medical credit card and loans and 
the role they play in the Indian health care provider billing 
environment. HHS additionally seeks to understand how medical payment 
products interact with Affordable Care Act and No Surprises Act 
protections and the prohibitions set forth in the Federal anti-kickback 
statute.\49\ Relevant Affordable Care Act protections include the right 
to seek an internal appeal and an external review of an insurance claim 
denial. Relevant No Surprises Act protections include surprise billing 
protections and good faith estimate rights for uninsured and self-pay 
patients (including the right to use a Federal dispute process to 
challenge a bill that is $400 or more higher than a patient's good 
faith estimate). Finally, HHS seeks to understand whether any financial 
institution or health care provider practices in connection with 
medical payment products may violate health care fraud and abuse laws, 
including the Federal anti-kickback statute.
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    \49\ 42 U.S.C. 1320a-7b(b), the Federal anti-kickback statute, 
provides for criminal penalties for whoever knowingly and willfully 
offers, pays, solicits, or receives anything of value to induce or 
reward the referral, recommendation, or arranging for the referral 
or recommendation of business reimbursable under any of the Federal 
health care programs, including Medicare and Medicaid. To assess the 
application of the Federal anti-kickback statute requires an 
examination of all of the facts and circumstances of an arrangement.
---------------------------------------------------------------------------

    HHS welcomes comment on the intersection of medical payment 
products with Federal health programs, Federal laws against health care 
fraud and abuse, and Affordable Care Act and No Surprises Act 
protections, including comments in response to any of the following 
specific questions:
    1. What actions should HHS consider taking to address problematic 
practices related to medical credit cards or loans, particularly as 
they relate to patients eligible for or enrolled in Medicare, Medicaid, 
or the Children's Health Insurance Program, or patients enrolled in 
Affordable Care Act Marketplace plans?
    2. What types of health insurance (Medicare, Medicaid, private 
insurance, etc.) are particularly associated with the likelihood that 
an individual is offered or makes use of medical credit cards and 
loans, and how does the type of health coverage affect relevant 
provider billing practices?
    3. Are there particular health care provider types that are most 
associated with being offered or offering medical payment products, and 
are these providers receiving directed payments or other incentives 
through State Medicaid programs?
    4. Has the No Surprises Act and its surprise billing protections 
affected the prevalence and use of medical credit cards and loans, and 
if so, how?
    i. Has the notice and consent process been used to promote medical 
cards and loans to patients seeking health care items or services from 
out-of-network providers/facilities, and if so, how? For example, in 
instances where the No Surprises Act permits providers and facilities 
to seek notice and obtain consent from an insured patient to waive 
their balance billing and cost-sharing protections under the No 
Surprises Act, are providers and facilities impermissibly attaching or 
incorporating medical card or loan documents or information to the 
notice and consent forms, or giving them to the patient at the same 
time as the notice and consent forms?
    ii. What steps are health care providers and facilities putting 
into place to ensure that bills paid through medical payment products 
do not violate surprise billing requirements and that patients who use 
medical payment products retain their No Surprises Act rights?
    5. How does or might the use of medical credit cards and loans 
affect the amount and timing of cost sharing a patient covered through 
Medicare, Medicaid, and/or the Affordable Care Act Marketplace owes for 
a covered service?
    i. Are there any observable differences in cost sharing among 
patients belonging to underserved communities, such as Tribal 
communities or geographically isolated communities?
    6. Hospital Price Transparency: What prices or versions of standard 
charges (e.g., cash prices) are offered to patients who sign up for a 
medical credit card or installment loan? What steps are taken by health 
care providers to ensure these charges are adequately disclosed in 
accordance with hospital price transparency requirements? Do these 
charges reflect and specifically identify facility fees?
    7. How might HHS improve patient understanding of options for 
covering the cost of medical treatments? At what points in the care 
process could patients be provided with information about

[[Page 44290]]

their financial obligations and payment options?
Anti-Kickback Statute
    HHS is interested in whether incentives offered to health care 
providers by financial companies may implicate the Federal anti-
kickback statute. Specifically, HHS is interested in the following 
questions:
    8. What financial relationships exist between medical payment 
product companies and health care providers? For example, do companies 
provide financial incentives to providers who enroll patients in 
medical payment products? Do providers pay financial companies to 
collect patients' overdue balances? Or, do providers have arrangements 
with financial companies to indemnify the company in whole or in part 
if the patient defaults, such as an arrangement that when patients 
default on their debt to the financial company, the debt reverts to the 
provider?
    9. Do health care providers or financial institutions market or 
recommend medical credit cards or loans to Federal health care program 
beneficiaries (e.g., Medicare, Medicaid, Affordable Care Act 
Marketplace, or Children's Health Insurance Program enrollees)? Is the 
use of these products limited to certain types of health care items or 
services, such as items and services that are not reimbursable by 
Medicare or another third-party payor?
    10. Do medical payment product companies recommend certain health 
care providers to their users? Do companies limit where or how patients 
use medical credit cards?
    11. Is the health care provider (or the medical payment product 
company) offsetting some of the patient's medical debt or providing any 
other incentives to the patient (e.g., travel rewards for charges to 
the card)?

d. Treasury-Specific Questions

    The Treasury Department oversees policy decisions relating to the 
Internal Revenue Code, including those provisions relating to tax-
exempt hospitals found in section 501(r). Section 501(r)(4) and 26 CFR 
1.501(r)-4 require tax-exempt hospital organizations to establish and 
widely publicize a written financial assistance policy that applies to 
all medically necessary care provided by the hospital organization. 
Section 501(r)(6) and 26 CFR 1.501(r)-6 require hospital organizations 
to make reasonable efforts to determine whether an individual is 
eligible for assistance under the hospital organization's financial 
assistance policy (FAP) before engaging in extraordinary collection 
actions against that individual. Extraordinary collection actions 
include credit reporting an unpaid medical bill, deferring or denying 
care to a patient due to their unpaid medical bills, taking legal or 
judicial action to recoup an alleged medical debt, or selling an 
alleged medical debt.
    However, selling an alleged medical debt is not considered an 
extraordinary collection action if, prior to the sale, the hospital 
facility enters into a legally binding written agreement with the debt 
buyer that meets four conditions: (1) the buyer agrees not to engage in 
any extraordinary collection actions to obtain payment; (2) the buyer 
agrees not to charge interest in excess of the rate in effect under 
section 6621(a)(2) at the time the debt is sold (currently set at 7 
percent through June 2023); (3) the debt is returnable to or recallable 
by the hospital facility upon a determination that the individual is 
financial assistance-eligible; and (4) if the individual is determined 
to be financial assistance-eligible and the debt is not returned or 
recalled, the buyer must adhere to specified procedures which ensure 
that the individual does not pay, and has no obligation to pay, the 
buyer and the hospital facility together more than that individual is 
personally responsible for paying under the financial assistance 
policy.
    Treasury welcomes comment on the interplay between the requirements 
that apply to tax-exempt hospitals and medical payment products, 
including comments in response to any of the following specific 
questions:
    1. What policy actions should Treasury consider taking to address 
problematic practices related to medical credit cards or loans, 
including debt collection and credit reporting practices, to conform 
with the existing tax laws and regulations pertaining to tax-exempt 
hospitals?
    2. Should a tax-exempt hospital's signing patients up for medical 
payment products be considered similar to a tax-exempt hospital's 
selling medical debt, such that the special rules that only exclude 
debt sales from being extraordinary collection actions if certain 
requirements are met would be applied to these payment products?
    3. How would applying the debt sale special rules to payment 
products change hospitals' and payment product providers' current 
practices, especially those related to financial assistance eligibility 
screening, extraordinary collection actions, interest rates, and recall 
or return of balances owed by FAP-eligible individuals?
    4. How do tax-exempt hospitals' promotion of medical payment 
products compare to their operationalization of the requirement that 
their financial assistance policies be widely publicized?
    5. What are best practices for hospitals publishing and making 
patients aware of financial assistance programs (beyond compliance with 
the widely publicized requirements found in the section 501(r) 
regulations)?
    6. Are medical payment product companies advertising their products 
as delivering community benefits or as a form of financial assistance?
    7. Are tax-exempt hospitals claiming that their promotion of 
medical payment products delivers community benefits or provides 
financial assistance, including in their filings of Form 990, Schedule 
H?
    8. Does the availability of medical payment products generally 
benefit the community or assist patients financially?

Signing Authority for HHS

    The Administrator of the Centers for Medicare & Medicaid Services 
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this 
document, authorizes Vanessa Garcia, who is the Federal Register 
Liaison, to electronically sign this document for purposes of 
publication in the Federal Register.

Rohit Chopra,
Director, Consumer Financial Protection Bureau.
Thomas C. West Jr.,
Deputy Assistant Secretary for Tax Policy, Department of the Treasury.
Vanessa Garcia,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-14726 Filed 7-11-23; 8:45 am]
BILLING CODE 4810-AM-P; 4120-01-P; 4810-AK-P