When in doubt, cut costs

Reuters is reporting on a disturbing situation in Lousiana. Individuals with a positive HIV status have been receiving federal help to purchase healthcare for the past two decades via the Ryan White Act. This act helps pay for prescription drugs and basic primary care for people who need AIDS and HIV treatment but otherwise can not afford it. Some portions of this Act provide premium support to buy private insurance.

All Exchange insurance plans in Louisiana are creatively misinterpreting CMS regulation and guidance in order to not accept Ryan White payments and therefore kick people with AIDS and HIV off of their plans for either non-payment of premiums or as risk/fraud/abuse risks.

The Center for Medicare and Medicaid Services (CMS) is the primary administrative and rule-making hub for federal guidelines on Medicare, Medicaid, Childrens Health Insurance Program (CHIP), and now the Exchanges. Congress and CMS has always intended for the Ryan White CARE Act’s goals to be achived through PPACA. For instance, CMS mentioned that Ryan White centers would be part of essential community services for all Exchange plans last April. Last September, CMS issued regulations that demonatrated an intent to continue Ryan White funding and premium assistance programs for individuals whose insurance situation moved to the Exchange.

In November 2013, CMS issued guidance on third party reimbursement of premiums. The goal of this guidance was to avoid double dealing and intentional wrecking of risk pools in a scenario where a hospital would pay the premium of a currently uninsured patient with chronic or repeated episodes of intervention needed conditions in order to get payments. This would destroy any randomness as the hospitals would only do this for their sickest/costliest patients.

The problem in Lousiana is all of the health plans recently read that guidance to apply to all third party payment support, including other federal programs. From this (mis)-reading, they are trying to disenroll anyone who has submitted Ryan White payments as a potential for fraud and abuse while coincidentally dramatically lowering expected medical loss costs.

CMS is punching back and basically calling the Lousiana insurers (and a North Dakota insurer) idiots in bureacratese:

The November 4, 2013 FAQ does not apply to payments for premiums and cost sharing made on behalf of QHP enrollees by Indian tribes, tribal organizations, urban Indian organizations, and state and federal government programs or grantees (such as the Ryan White HIV/AIDS Program). QHP issuers and Marketplaces are encouraged to accept such payments.
As CMS stated in its 2015 Draft Letter to Issuers on Federally-facilitated and State Partnership Exchanges,2 pursuant to section 1312 of the Affordable Care Act, section 402 of the Indian Health Care Improvement Act, and 45 CFR 155.240(b), a Marketplace may permit Indian tribes, tribal organizations, and urban Indian organizations to pay QHP premiums on behalf of members who are qualified individuals, subject to terms and conditions determined by the Marketplace. Indeed, Federal law specifically provides for this approach.
In addition, guidance from the Health Resources Services Administration (HRSA) on the Ryan White HIV/AIDS Program3 specifically describes how grantees can use grant funds to pay premiums and cost sharing for eligible individuals enrolled in QHPs.

So why is this happening?

If I squint hard enough, I can see the fuzziness in the language, especially if I am only looking at the November FAQ from CMS. That fuzziness can lead to the leading insurer in Louisiana to make the choice of reducing claims costs by kicking out several hundred people with high medical needs and the other two Exchange insurers have to follow suit as their risk pools would get destroyed if they picked up every AIDS patient in Louisiana. This happened in two states where the regulators aren’t particulary keen on making PPACA work, so there is no local pushback from state regulators. It takes a bit of time for issues to escalate to CMS attention, so if the assumption is do anything that is plausible to minimize claims impact, I can see this happening.

27 replies
  1. 1
    Nate Dawg says:

    A blatant attempt to get people who had government assisted insurance to turn against Obamacare. Similar to telling seniors how Ocare woul destroy their Medicare coverage. Just sick.

  2. 2
    Nate Dawg says:

    A blatant attempt to get people who had government assisted insurance to turn against Obamacare. Similar to telling seniors how Ocare woul destroy their Medicare coverage. Just sick.

  3. 3
    Belafon says:

    So, evil people will do evil things with good laws. It’s not the law, but the people in charge. All the more reason to keep some people out of office.

  4. 4
    CambridgeChuck says:

    Actually, losing Ryan White coverage can be pretty deadly, even if it’s just temporary. Most of us with AIDS rely to some extent or another on that coverage, for some portion of the high costs associated with treatment. Even if this coverage is ultimately restored, the probable break in treatment is likely to result in lost lives.

  5. 5
    maximiliano furtive, formerly known as dr. bloor says:

    If I squint hard enough, I can see the fuzziness in the language

    An adaptive trait in the insurance industry.


  6. 6
    c u n d gulag says:

    “So why is this happening?”

    Could it be that too many of our uber-Christians think that ‘God hates f*gs?’

    I would think what a God who they believe created EVERYthing, would love everyTHING equally – and hate intolerance of that which He/She/It created and loves.

    But wtf do I know?
    I’m an Agnostic!

  7. 7
    Shakezula says:

    So why is this happening?

    Homophobic cockbags will be homophobic cockbags.

  8. 8
    maximiliano furtive, formerly known as dr. bloor says:

    @CambridgeChuck: I think the phrase you’re looking for is “bending the cost curve.”

  9. 9
    Punchy says:

    Rick’s quick sick schtick is slick.

  10. 10
    Violet says:

    I don’t visit Andrew Sullivan’s site anymore, but he’s HIV positive and I guess he must be on the HIV medications. Is he covering this story? Anyone know?

  11. 11
    Pogonip says:

    It’s not just AIDS. I have a one-pill-a-day prescription that I’m not supposed to interrupt. Anthem will pay for it every 30 days. How many days are there in January? 31! How about that? So I have to pay for it.

  12. 12
    boatboy_srq says:

    @Shakezula: Grayson’s interpretation of the GOTea health insurance plan as “Die quickly” has never been so clearly (and brutally) illustred as in Louisiana. As an added plus they get to beat up some f@gg0ts and druggies Other people they don’t like.

  13. 13
    slippytoad says:

    Looks like more Southern Hospitality at work to me. I’ve had my fill of that by the way. I’d like for people to never try it on me again, because I’ve lived here too long and I know the minute you round the corner the motherfuckers are cutting you down one side and up the other.

    At any rate, yeah, them’s some fine Christian values there. Lie in order to magnify your inbred dumbass prejudices and allow yourself to indulge in them, whenever you possibly can, no matter how ugly and fucking stupid it makes us all look.

  14. 14
    maximiliano furtive, formerly known as dr. bloor says:

    @c u n d gulag: They don’t hate gay people. They hate sick people.

  15. 15
    BubbaDave says:

    This is why I hate Southern white Christians. And I am one.

  16. 16
    boatboy_srq says:

    @maximiliano furtive, formerly known as dr. bloor: To them, there’s a difference?

  17. 17
    TaMara (BHF) says:

    Hey Richard, since I’m the one who bitched the loudest, I wanted to update you on my insurance sitch.

    I had to wait until I knew what my income was for 2013 because 2nd quarter I went from part time business, full time employee, to full time business, not an employee. Once I did my taxes and got that all sorted out, I had a better idea of what 2014 MIGHT look like (still unsure but did my best guess) and got my Obamacare all set up.

    Once the kinks worked out of the system, by end of the year, it was easier to see what I would be paying after my tax credit (when it first came out there was no easy way to see your after credit price). After reading a few Kaiser docs and talking to a rep, I found a good plan (not great, but I’m not big on doctors and really not big on prescription meds, so went with the very basics) that I could afford. The deductible is insane, but I’ll take that over high premiums.

    Probably took me about 2 hours of research and an actual 45 minutes to sign up.

    Picking from the plans is downright stressful – but it would be no matter how I got my health insurance. The signup was easy.


  18. 18
    Scott S. says:

    Shouldn’t there be a fraud investigation in this? If they’re deliberately misinterpreting the law to bar people from coverage, shouldn’t they be in jail for fraud?

  19. 19
    slippytoad says:

    @Scott S.:

    Oh, I think that’s a bit much. Fraud for lying about the law to ensure political gain and harm to a class you don’t like?

    No, I don’t think fraud covers it. Despicable shitstain human behavior.

  20. 20
    boatboy_srq says:

    @Scott S.: Jail? Probably not. Barred from public office? Without a doubt – oh, right, Louisiana.

  21. 21
    The Very Revered Crimson Fire of Compassion says:

    I saw this in Missouri, twenty years ago. We fought like animals, and things–ever so slowly and a shitload of deaths later–got better. Now the state is lurching to the right again. These days I teach kids with psychological and emotional issues. When we talk about history, we talk about how things got the way they are. And I always have to remind the kids that these people are still here. They haven’t stopped hating you for being who you are. They haven’t stopped trying to hurt you and hold you down. It’s enough to make me want to believe in white man’s hell, sometimes. But we tend our gardens. We do what we can. And it matters.

  22. 22
    Richard Mayhew says:

    @boatboy_srq: It’s a subset not the entire set

  23. 23
    maximiliano furtive, formerly known as dr. bloor says:

    @boatboy_srq: These aren’t office holders that are misreading the law. They’re insurance company execs.

  24. 24
    Richard Mayhew says:

    @Scott S.: That is why each health plan has someone in charge of PLEASE (Provider Legal Exculpation And Sign Everything) services. If you squint hard enough and are deliberately incompetent, you get the incompetent defense for fraud.

  25. 25
    boatboy_srq says:

    @Richard Mayhew: Not suggesting that to them sick people are queer, but that queer people are sick; differentiating based on that last sentiment has minimal utility (especially when discussing sick queer people).

  26. 26
    boatboy_srq says:

    @maximiliano furtive, formerly known as dr. bloor: IOW, greedy and hardhearted by definition, rather than incompetent by philosophy. And jail is still as likely to happen for the former group as an en masse booting out of office is for the latter.

  27. 27
    rikyrah says:

    These are some evil ass mofos

Comments are closed.