ModifiedMedicarePolicy CMS-9943-IFC

Third‑Party Payment Acceptance by QHPs and SADPs (Interim Final Rule, CMS-9943-IFC)

Requires individual market QHPs and Stand‑Alone Dental Plans to accept premium and cost‑sharing payments from the Ryan White HIV/AIDS Program, Indian tribes/tribal organizations/urban Indian organizations, and certain state and federal programs; applies across FFEs, SBEs, and outside Exchanges.

Policy Summary

PayerMedicare

PolicyThird‑Party Payment Acceptance by QHPs and SADPs (Interim Final Rule)

Policy CodePolicy CMS-9943-IFC

Change TypeAdded §156.1250Revised §156.805Clarifications

Effective Date

Next Review Date

Key ActionIssuers must accept premium and cost‑sharing payments from Ryan White, Indian tribes/tribal organizations/urban Indian organizations, and specified state and federal programs.

SourceLink

POLICY UPDATE CHANGES

New §156.1250 requires QHPs and SADPs to accept third party premium and cost-sharing payments from the Ryan White HIV/AIDS Program, Indian tribes/tribal organizations/urban Indian organizations, and state and federal government programs.

Amendment to §156.805 and related enforcement language to clarify that violations of new §156.1250 can be enforced and may be subject to civil money penalties.

CMS restated prior FAQ guidance to encourage acceptance of third-party payments from tribes and government programs and discouraged acceptance from hospitals and commercial entities.

52,568people receiving Ryan White assistance

$397MRyan White premium assistance (FY2013)

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$100/daymax CMP (FFE)

FFEs, SBEs, outside Exchangesmarkets affected

3required payer categories

Third‑Party Payment Acceptance Criteria

Acceptance and enforcement criteria

Covered when ALL of the following conditions apply:

Issuers of individual market Qualified Health Plans (QHPs) and Stand‑Alone Dental Plans (SADPs) must accept premium and cost‑sharing payments made by specified third‑party entities as required by §156.1250.

The acceptance requirement applies regardless of whether the plan is offered through a Federally Facilitated Exchange (FFE), a State‑Based Exchange (SBE), or outside of the Exchanges.

Issuers may continue to contractually prohibit acceptance of third‑party payments from entities other than those specified (for example, hospitals, other health care providers, and commercial entities); CMS discourages such payments due to potential adverse market effects.

Failure to accept required third‑party premium or cost‑sharing payments may be treated as substantial noncompliance under §156.805 and may trigger enforcement remedies, including civil money penalties for FFE issuers (up to $100 per day per adversely affected individual) and SBE/state penalties where applicable.

Qualified individuals adversely affected by an issuer's noncompliance in states with an FFE or SPE may be eligible for an FFE special enrollment period (§155.420(d)(9)) and a certificate of exemption (§155.605(g)(1)(iii)); CMS will provide further guidance on SEP and hardship exemption criteria.

Third‑party payers required

Issuers must accept premium and cost‑sharing payments from ONE or more of the following third‑party payers when made on behalf of plan enrollees:

Ryan White HIV/AIDS Program (under title XXVI of the Public Health Service Act).

Indian tribes, tribal organizations, or urban Indian organizations.

State and Federal Government programs that provide premium or cost‑sharing support to specific individuals.

Enforcement References and Penalty Metrics

Enforcement referencesmixed

No codes listed

Civil money penalty maximum (FFE)

Maximum civil money penalty (FFE)Up to $100 per day, per each individual who is adversely affected by the issuer's non-compliance (maximum under §156.805(c) for FFE issuers)

ApplicabilityApplies to issuers offering QHPs or SADPs through a Federally-facilitated Exchange (FFE)

Basis in regulationPenalty authority is set forth in §156.805(c) as part of enforcement provisions for FFE issuer standards

State and SBE enforcementIssuers in SBEs or outside Exchanges are subject to any penalties established by the SBE or state in addition to other enforcement mechanisms

What Issuers Must Do

Billing Rule

Required acceptance of specified third‑party payments

QHPs and SADPs must accept specified third‑party payments for premiums and cost‑sharing when those payments are made on behalf of enrollees by the entities listed below. This is an operational requirement for all issuers offering individual market QHPs and SADPs (including stand‑alone dental plans), regardless of whether coverage is offered through an FFE, an SBE, or off‑Exchange.

Applies to premium and cost‑sharing payments
Covers all individual market QHPs and SADPs, including SADPs offered outside Exchanges

Note

Acceptance of certain third‑party payments (§156.1250)

QHPs and SADPs must accept third‑party premium and cost‑sharing payments made by: (a) the Ryan White HIV/AIDS Program under title XXVI of the Public Health Service Act; (b) Indian tribes, tribal organizations, or urban Indian organizations; and (c) State and Federal government programs. Issuers may continue to prohibit acceptance of payments from other third parties (for example, hospitals or commercial entities). CMS continues to discourage acceptance of payments from hospitals, other health care providers, or commercial entities because of risk to the risk pool balance.

Key Terms

QHP — Qualified Health Plan

TermQualified Health Plan (QHP)

DefinitionPrivate health insurance certified to meet Exchange standards and offered through Marketplaces (Exchanges), including State-based Exchanges (SBEs) and Federally-facilitated Exchanges (FFEs)

ScopeQHPs include plans available to qualified individuals and employers through Exchanges beginning January 1, 2014

§156.1250 — Acceptance of certain third party payments

Regulatory citation§156.1250 Acceptance of certain third party payments

Who must complyIssuers offering individual market QHPs, including stand-alone dental plans (SADPs)

Policy Summary

PayerMedicare

PolicyThird‑Party Payment Acceptance by QHPs and SADPs (Interim Final Rule)

Policy CodePolicy CMS-9943-IFC

Change TypeAdded §156.1250Revised §156.805Clarifications

Effective Date

Next Review Date

Key ActionIssuers must accept premium and cost‑sharing payments from Ryan White, Indian tribes/tribal organizations/urban Indian organizations, and specified state and federal programs.

SourceLink

On This Page

Ryan White HIV/AIDS Program
Indian tribes, tribal organizations, urban Indian organizations
State and Federal government programs

Denial Risk

Enforcement and penalties for noncompliance — highlight risk and enforcement under §156.805

Failure to comply with §156.1250 can trigger enforcement under §156.805. For FFE issuers, violations may be treated as practices that deny or discourage enrollment and may be subject to civil money penalties (up to $100 per day per affected individual under §156.805(c)). SBEs and states may apply their own enforcement processes and penalties for issuers operating through an SBE or outside the Exchanges. Affected qualified individuals in FFEs or SPEs may be eligible for a special enrollment period under §155.420(d)(9) and a certificate of exemption under §155.605(g)(1)(iii); CMS will provide additional guidance on SEP and hardship exemption criteria.

FFE CMP authority: up to $100 per day, per affected individual
SBEs/states: subject to state/SBE enforcement mechanisms
Affected enrollees may qualify for SEP or hardship exemption

Required third-party payers

Ryan White HIV/AIDS Program; Indian tribes, tribal organizations, and urban Indian organizations; State and Federal government programs that provide premium or cost‑sharing support to specific individuals

Market scopeApplies to individual market QHPs and SADPs regardless of being offered through an FFE, an SBE, or outside the Exchanges

§156.805 — Enforcement and civil money penalties

Regulatory citation§156.805 Enforcement of FFE issuer standards and civil money penalties

Amendment purposeAmended to clarify that enforcement remedies under part 156, including new §156.1250, may be a basis for imposing CMPs

Enforcement scopeSubstantial non-compliance with any Exchange standard or requirement applicable to issuers in the FFE can be grounds for CMPs; clarifications remove unintended limits referencing specific subparts of part 153

Small entity — Regulatory Flexibility Act definition

RFA definition — firmsA 'small entity' includes a proprietary firm meeting Small Business Administration (SBA) size standards

RFA definition — nonprofitsA 'small entity' includes a not‑for‑profit organization that is not dominant in its field

RFA definition — governmentsA 'small entity' includes a small government jurisdiction with a population of less than 50,000 (states and individuals are excluded)

CMS threshold for impactCMS uses a change in revenues of more than 3% as its measure of significant economic impact on a substantial number of small entities

Estimated small issuersCMS estimated approximately 28 small entities with less than $7 million in Accident and Health earned premiums (MLR analysis)