Health Plan Payment and Reimbursement

HFMA Comments on Interim Final Rule on Third Party Payment of Qualified Health Plan Premiums

May 12, 2014 11:20 am

May 6, 2014

Marilyn Tavenner
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8011
Baltimore, MD 21244-1850

Re: CMS-9943-IFC Patient Protection and Affordable Care Act; Third Party Payment of Qualified Health Plan Premiums

Dear Ms. Tavenner:

The Healthcare Financial Management Association (HFMA) would like to thank the Centers for Medicare & Medicaid Services (CMS) for the opportunity to comment on CMS’s recent interim final rule (IFR) concerning third party payment of qualified health plan (QHP) premiums. HFMA is a professional organization of more than 40,000 individuals involved in various aspects of healthcare financial management. HFMA is committed to helping its members improve the management of and compliance with the numerous rules and regulations that govern the industry. 


HFMA appreciates CMS’s effort in the IFR to codify the guidance related to third party premium payment for individuals enrolling in QHPs. However, we also find the IFR flawed as it does little to resolve the ambiguity created by CMS’s somewhat conflicting statements on the issue. 

Open Questions

Unfortunately, there are issues that the IFR fails to address. In order to resolve the ambiguity surrounding the roles that healthcare providers, their private, not for profit foundations, and private, not-for-profit foundations that are not affiliated with healthcare providers can play in assisting indigent and near-indigent individuals in obtaining qualified healthcare coverage, CMS needs to promulgate regulations in the Federal Register addressing the following:

  • CMS issued a FAQ dated February 7, 2014 related to Third Party Premium Payments for QHPs in the Marketplaces. The second question (Q2) and its related answer state that CMS’s November 4, 2013 FAQ document (encouraging QHPs to reject third party payments for coverage) does not apply to private, not-for profit foundations. However, the IFR is silent on this issue. 
  • An October 31, 2013 letter to Congressman Jim McDermott (D-WA) stated that QHPs were not federal health care programs and thus presumably were not subject to the anti-kickback laws. That raised the possibility that hospitals or other providers could pay premiums for QHP enrollees. On November 4, 2013 HHS released a FAQ document encouraging insurers to not accept premium payments from hospitals or other healthcare providers or commercial entities. While CMS did not clarify on what authority it based the FAQ, the document, subsequent FAQs, and correspondence with Senator Charles Grassley (R-Iowa) have created sufficient ambiguity within the provider community to prevent many organizations from establishing programs to help purchase QHP coverage for individuals who cannot afford it. 
  • Providers are deeply concerned that given the ambiguity, and the relatively little weight FAQs and general correspondence carry compared to regulations promulgated in the Federal Register, the decision that QHPs are not federal health programs may be reinterpreted exposing healthcare providers who have provided third party QHP coverage for individuals who could not afford it to unintended violations of the anti-kickback statute. 

HFMA looks forward to any opportunity to provide assistance or comments to support CMS’s efforts to expand healthcare coverage to individuals who need it most. As an organization, we take pride in our long history of providing balanced, objective financial technical expertise to Congress, CMS, and advisory groups.

We are at your service to help CMS gain a balanced perspective on this complex issue. If you have additional questions, you may reach me or Richard Gundling, Vice President of HFMA’s Washington, DC, office, at (202) 296-2920. The Association and I look forward to working with you.


Joseph J. Fifer, FHFMA, CPA
President and Chief Executive Officer
Healthcare Financial Management Association

About HFMA

HFMA is the nation’s leading membership organization for more than 40,000 healthcare financial management professionals. Our members are widely diverse, employed by hospitals, integrated delivery systems, managed care organizations, ambulatory and long-term care facilities, physician practices, accounting and consulting firms, and insurance companies. Members’ positions include chief executive officer, chief financial officer, controller, patient accounts manager, accountant, and consultant.

HFMA is a nonpartisan professional practice organization. As part of its education, information, and professional development services, HFMA develops and promotes ethical, high-quality healthcare finance practices. HFMA works with a broad cross-section of stakeholders to improve the healthcare industry by identifying and bridging gaps in knowledge, best practices, and standards.


googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text1' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text2' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text3' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text4' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text5' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text6' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text7' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );