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Urge HHS to Finalize Rule Supporting Insurance Plan Premium and Out-of-Pocket Assistance

on Wed, 03/19/2014 - 18:13

Tim Horn, HIV Project Director

Federal HIV policy advocates, including the HIV Medicine Association and Harvard's Center for Health Law and Policy Innovation, have issued a simple, but critical, request for public comments supporting an interim final rule by the Centers for Medicaid & Medicare Services (CMS) requiring insurers to accept premium assistance and cost sharing from Ryan White programs. There's also a need to urge CMS to amend the rule to encourage insurers to accept industry co-pay assistance for high cost medications without generic alternatives (e.g., standard-of-care medications for HIV, viral hepatitis and a number of other chronic diseases).

Comments are due on May 13, 2014 by 11:59 pm EST.  Comments can be submitted electronically via  

On March 14, the U.S. Department of Health and Human Services (HHS) released its interim final rule requiring insurers to accept Ryan White premium assistance payments—an important clarification in light of the recent debacle in Louisiana. CMS waived the normal rulemaking procedures and the rule became effective on that date. There is a 60-day comment period, after which HHS can alter the rule as it sees fit—it can improve it, water it down, or even withdraw it entirely. 

This is a hard-won victory for community advocates and it is important that we submit comments letting HHS know how essential this rule is for preserving the health of people living with HIV/AIDS.  We need such letters to balance out complaints HHS will likely receive from the insurance companies.

Unfortunately, the HHS rule also discourages the use of specific third-party payment programs intended to help defray out-of-pocket costs, notably co-pay assistance programs that have been implemented by pharmaceutical companies. For many people living with HIV and viral hepatitis, these programs have long been financial lifelines. These programs will also be tremendously helpful for individuals enrolled in Affordable Care Act-mandated Qualified Health Plans (QHPs), particularly insurance policies that restrict expensive prescription drugs (without generic equivalents) to specialty formulary tiers that command high copayments or coinsurance costs that can reach 40% to 50% of the drug’s price.  

As per the HHS interim rule issued on March 14:

Our new standard does not prevent QHPs and [stand-alone dental plans, or SADPs] from having contractual prohibitions on accepting payments of premium and cost sharing from third party payers other than those specified in this interim final regulation. In particular, as stated in our November FAQ, we remain concerned that third party payments of premium and cost sharing provided by hospitals, other healthcare providers, and other commercial entities could skew the insurance risk pool and create an unlevel competitive field in the insurance market. We continue to discourage such third party payments of premiums and cost sharing, and we encourage QHPs and SADPs to reject these payments.

Advocates are urging the submission of letters to HHS, similar to this one below:

We, [Name of Organization or Individuals], thank the Administration for the interim final rule requiring issuers of Qualified Health Plans (QHPs) to accept premium and cost-sharing payments made by the Ryan White HIV/AIDS Program and other federal and state programs.  We urge the Administration to finalize the rule as written. Enactment of this rule will reduce insurance practices that severely restrict enrollment by people living with HIV and other significant health needs in Marketplace QHPs. Such practices are discriminatory insurance practices that greatly impede access to health care and are inconsistent with the intent of the Affordable Care Act. They undermine efforts to provide access to comprehensive coverage for nearly every American, regardless of health status or income.

While we applaud the Administration for addressing this discriminatory practice, we urge you to take action to address the extraordinary and also discriminatory cost sharing that many QHPs are charging for medications to treat HIV, hepatitis C and other complex chronic conditions. This practice is being compounded by previously issued guidance and this rule strongly discouraging insurers from accepting third-party payments from commercial entities, including industry co-pay assistance programs. These resources previously have been widely available in insurance markets and are critical to people with HIV, hepatitis C and other conditions that rely on high cost medications without generic alternatives. We strongly recommend that you modify the rule by urging insurers to allow co-pay assistance for medications that do not have generic alternatives. Failure to make this assistance available will leave lifesaving medications out of reach for many people with HIV, hepatitis C and other complex chronic conditions.