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Mon Apr 14, 2014, 06:18 PM

Can a Concerned Third Party Make Your ACA Premium Payment for You? Not a Simple Question

Serious question. In this month's Texas Medical Association magazine, there is an article in which they warn providers that there is no way to know that a patient is actually covered by ACA insurance due to the premium payment grace period loophole. When the doctor and hospital call for eligibility, the insurer will say "Yeah, he is covered." The insurance is not required to mention that the patient is late with his last payment. The problem comes if the patient decides not to make last month's premium payment of $100 bucks after the surgery. If he never makes that payment, the health plan can then go back to the doctor and hospital and demand that all of its money be refunded. But before they take back the money they have to warn you "Your patient has not made a payment. Time is running out." If this happens, the article warns, doctors and hospitals are advised NOT to make the premium payment for the patient, at least that is the recommendation of the CMS.

http://www.texmed.org/Template.aspx?id=30281

Why not? What happens if you pay the $100 bucks for the insurance so that you get to keep the $5000 that you earned?

That is not a rhetorical question. CMS has said "Don't do it." Why not? Do you get hauled into court, charged with committing some kind of fraud? I.e "The patient only stayed in the hospital and had the life saving appendectomy because the hospital agreed to pay his $100 insurance premium. Had they not agreed to pay that premium, he obviously would have walked out the door and died." Yes, it sounds stupid. But replace "appendectomy" with something elective like "chiropractic manipulation" and maybe the insurance company has a case. According to Medicare, failure to do something as simple as charge a patient a copayment is "fraud" designed to drum up business and bilk the government out of money.

Lots of rural areas can not keep doctors or hospitals, because their poor and/or self employed residents do not have health insurance. In the 24 states that did not take the Medicaid expansion, rural areas are in big trouble. Is there any law that would prevent a rural county in Texas from coming up with the money to pay the additional premiums to buy all of its poor and uninsured citizens silver or even gold insurance under the Affordable Care Act?

How about large urban areas, like Dallas County, which often spend a lot of money running public health clinics for the uninsured? Could they legally pay the patient's portion of the insurance premiums for a private insurer?

http://healthcare.dmagazine.com/2013/10/04/dallas-hospital-may-pay-patients-obamacare-insurance-premiums-to-save-money/

Parkland is considering paying the Affordable Care Act insurance exchange premiums for some of its patients, a move that would help stem the tide of uncompensated care, WFAA reports.

snip

Parkland executives will be studying the policies on the federal health insurance exchange, then deciding. In 2012, Parkland spent $685 million on uncompensated care.


Can Parkland in Dallas, which serves a huge population of sick lower income workers legally dip into its deep pockets and pay the premiums of its working patients who qualify for ACA so that it can then bill their ACA insurer for the care they receive at Parkland Hospital and its clinics? Keep in mind that a Parkland patient is not your typical patient. Your Parkland patient is the one that used to be called "uninsurable"--lupus, sickle cell, cancer, renal failure, heart failure--you name it. The privates hope that lack of money---i.e. the poverty that accompanies being chronically ill---will keep these folks off their plans in states that did not take the Medicaid expansion. They hope that they will be stuck on the so called "bronze" plans with high deductibles and no participating providers in their part of town and no drug coverage--so they never use their new insurance, they will just keep getting uncompensated care at their local Parkland. So, what happens if Parkland tells Blue Cross, Blue Shield "Here's your $50,000 check for this month's premiums for our 1000 patients who have you ACA insurance---and here's your bill for their $500,000 in care"?

We know that a third party without a financial concern can make the payments. And we know that insurers do not want any third parties making anyone's payments.

http://www.aidsmeds.com/articles/aca_louisiana_ryan_white_1667_25269.shtml

Three Louisiana health insurance companies have agreed to continue accepting federally-funded third-party payments for premiums, according to a statement from the LGBT group Lambda Legal, which with the New Orleans AIDS Task Force filed a federal class action discrimination lawsuit against the insurers.

Blue Cross and Blue Shield (BCBS) of Louisiana was the first to decide not to accept third-party payments. BCBS was going to discontinue accepting those payments as of March 1. After that decision by BCBS, Louisiana Health Cooperative and Vantage Health Plan also decided to discontinue accepting those payments.

snip

BCBS claims to have made its initial decision based on 2013 guidance from the Centers for Medicare and Medicaid Services (CMS), which cited the risk of fraud as a concern in accepting third-party payments. However, a spokesperson for CMS has clarified payments from the Ryan White program should remain acceptable.

If the initial decisions by the insurers had been implemented, many hundreds of people with HIV/AIDS in Louisiana receiving assistance under the federal Ryan White CARE Act who enrolled in plans under the Affordable Care Act (a.k.a. the health care reform law, or ACA) would have been in danger of losing their ACA health care coverage


Insurance plans will only make a profit under the ACA if the number of healthy people signing up outweighs the number of chronically ill people. In the United States, "Sick and Poor" is something you hear a lot, because illness and poverty go hand in hand. If you are too sick to work, you are poor. If you are poor, you can not well. That $50 to $150 means tested monthly premium may be all that stands between a private health insurer and bankruptcy---and it may be all the stands between life and death for one chronically ill individual.

Which matters more? The health of the health insurance industry that makes up the backbone of the ACA or the healths of the individual men and women whom the ACA is here to serve? Note: there is no answer to this one. It's just here to make us think. Life is full of hard choices.

6 replies, 1072 views

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Reply Can a Concerned Third Party Make Your ACA Premium Payment for You? Not a Simple Question (Original post)
McCamy Taylor Apr 2014 OP
Tarheel_Dem Apr 2014 #1
surrealAmerican Apr 2014 #2
ProSense Apr 2014 #3
Ms. Toad Apr 2014 #6
JimDandy Apr 2014 #4
dem in texas Apr 2014 #5

Response to McCamy Taylor (Original post)

Mon Apr 14, 2014, 06:21 PM

1. !!!

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Response to McCamy Taylor (Original post)

Mon Apr 14, 2014, 06:32 PM

2. Providers paying premiums is one thing I had not considered before.

This could get interesting, but I still can't see it happening often enough to make much of a difference.

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Response to McCamy Taylor (Original post)

Mon Apr 14, 2014, 06:39 PM

3. Here's some

information to pass onto the subject of your last OP:

http://www.dailykos.com/comments/1291854/53149263#c231

Anyone who doesn't qualify for Medicaid after the expansion will be qualifed for additional subsidies available with a silver plan. In some cases, those plans reduce the deductible to zero.

Texas:

94% Cost Sharing Benefits Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductible (Individual) $0.00
Deductible (Family) $0.00
Out of Pocket Maximum (Individual) $500.00
Out of Pocket Maximum (Family) $1,500.00

http://www.valuepenguin.com/health-insurance/TX/blue-cross-blue-shield-blue-advantage-silver-hmo-004

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Response to ProSense (Reply #3)

Tue Apr 15, 2014, 08:05 AM

6. You had the same thought I did. n/t

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Response to McCamy Taylor (Original post)

Mon Apr 14, 2014, 06:56 PM

4. Interesting question.

The increasing level of poverty in the US means an answer will be coming soon.

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Response to McCamy Taylor (Original post)

Mon Apr 14, 2014, 07:36 PM

5. There is a reason that Parkland is considering this

Money wise, it is the a smart choice. Parkland will lose more money when treating these people if Parkland does not pay for their insurance. If Texas had chosen to take expanded Medicaid, most of these people would be covered there. Parkland picks up lots of costs for the poor sick in the surrounding counties also. I saw a show on local TV, about ten years ago, about how Dallas County had to "eat" over 30 million in cost from Parkland that other counties should be paying. That same night, on the news, the budget director of Collin county was bragging about having a surplus. At that time, Collin county did not provide any type of free medical care for their poorer residents, instead, let them drive down the road to go to Parkland. As a taxpayer in Dallas County, I think Parkland should do what is the best choice for them and the Dallas county residents,so they don't lose more money.

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