Charitable assistance: the new pre-existing condition
September 1, 2016
Published by The Hill Congress Blog
For years, health insurance companies systematically denied coverage to Americans with pre-existing medical conditions. As a result, those who needed coverage the most—people with severe and chronic conditions—were unable to buy insurance or were charged exorbitant premiums that were equivalent to a denial of insurance.
Today, insurers can no longer deny coverage to sick people and cannot place a cap on benefits paid to treat their illnesses. For many patients, this access to insurance and treatment is crucial to their wellbeing and, often, their lives.
But now insurers are engaging in a different kind of effort to avoid covering people with expensive illnesses by refusing to accept premium payments from third-party charities that help low-income patients pay their premiums. In other words, charitable assistance is insurers’ new “pre-existing condition.”
Insurance industry lobbyists are working hard to exclude the sickest and most vulnerable patients from having a choice in their insurance. Patients with end-stage renal disease (ESRD) are a case in point.
Nearly half a million people in the United States depend on dialysis to survive. Most are unable to work because dialysis is both physically taxing and life-consuming. These patients have two options to cover the expense of the treatments that keep them alive: private insurance or enrollment in Medicare or Medicaid.
The American Kidney Fund (AKF) has been an important part of the health care safety net for dialysis patients. For the past 20 years AKF has provided charitable assistance to low-income dialysis patients, under a federally approved program, to help them afford both public and private insurance coverage.
When it comes to health insurance there is no one-size-fits-all. Under longstanding federal regulation, ESRD patients have a choice. Medicare is a great program but often must be supplemented by a private Medigap plan or Medicaid. Yet in about half the states, insurers are not required to offer Medigap to ESRD patients under age 65 ESRD patients are prohibited from enrolling in Medicare Advantage, which provides comprehensive coverage through private health plans. For some patients, private plans purchased on the insurance Marketplaces may be the best option. HHS recognized the unique circumstances of ESRD patients when it provided an exemption allowing them to buy coverage in the Marketplace. This is the choice insurance industry lobbyists are trying to take away.
Recently the Centers for Medicare & Medicaid Services (CMS) announced it will investigate alleged efforts by dialysis providers to steer patients eligible for Medicare and Medicaid into private insurance plans paid for by third parties. We agree there is no room for undue influence over patients in choosing their insurance.
At the same time, it is vitally important that people with ESRD not be broadly excluded as a class from access to the insurance Marketplace. Third-party payments from charitable organizations are a lifeline for many low-income, chronically ill patients. They must depend on charities to help them pay many of their expenses, including health care premiums. Cutting off this assistance would be particularly callous and would harm some of our nation’s most vulnerable people.
The allegations of fraud underscore the need for guardrails to protect the integrity of charitable support for insurance premiums. The U.S. Health and Human Services Office of the Inspector General has provided standards for third-party assistance in the payment of insurance premiums to bar specific practices that might steer patients into particular plans or to particular health care providers. Those standards have served patients well for almost 20 years as AKF has helped them with the cost of premiums for Medicare, Medigap, COBRA, employer group health and, since the passage of the Affordable Care Act, insurance Marketplace policies. Those guardrails can and should be continuously strengthened.
ESRD patients who choose to get coverage in the Marketplaces often need help paying for their policies. Even with the subsidies provided by the federal government, these patients often cannot afford the remaining monthly payments. This is a population that is overwhelmingly unable to work because of their medical condition. They need help and federal and state policymakers need to reject the efforts of the health insurance industry to take it away.
The Patient Protection and Affordable Care Act of 2010 was a historic step to guarantee people with chronic conditions the right to choose the coverage they need and get the help they can to pay for it. Let’s not let insurers treat charitable assistance the way they once treated pre-existing conditions. ESRD patients – and others like them – must have access to the care they need to stay alive.
LaVarne A. Burton is the President and Chief Executive Officer of the American Kidney Fund, the nation’s leading non-profit working on behalf of the 31 million Americans with kidney disease.