Payments of Member Premiums by Non-Profit Organizations
Non-profit organizations interested in paying premiums for individuals who purchase health insurance coverage from BlueCross BlueShield of Tennessee, Inc. on and off the Marketplace must apply for and receive approval from Blue Cross Blue Shield of Tennessee, Inc. in order for payments by such organizations to be accepted by BlueCross BlueShield of Tennessee, Inc. This policy, as further described below, will apply to premiums for health insurance coverage issued for the 2017 benefit year and thereafter.
BlueCross BlueShield of Tennessee (“BlueCross” or “We” or “Our”) joins the federal government, including the U.S. Department of Health and Human Services and its Centers for Medicare & Medicaid Services (“CMS”), and other organizations in the concern that payment of an individual’s premium for health care by a third-party can be problematic for the Marketplace. For example, payment of premiums by health care providers, such as a hospital or physician, can give rise to questions about conflicts of interest. CMS discourages health care providers from making premium payments and encourages health insurance issuers, such as BlueCross, to reject such payments. Payments of premiums by third-parties also can increase the risk of adverse selection for the Marketplace, thus negatively affecting the cost of health insurance for all Tennesseans. BlueCross also recognizes the important role played by certain foundations and other non-profit organizations in assisting individuals with their health insurance premiums so that these individuals continue to have access to health care coverage.
To balance these considerations, we are implementing this policy regarding payment by third-parties of premiums for health insurance coverage.This policy, which is effective for health insurance coverage issued for the 2017 benefit year and thereafter, applies to individual health insurance coverage issued by BlueCross.This policy applies to Medicare Advantage insurance coverage issued for the 2018 benefit year and thereafter. This includes coverage issued on or off the Federally Facilitated Marketplace (“FFM”) and regardless of whether the individual is simultaneously enrolled in Medicaid or has other coverage, coverage issued to an individual subscriber (including any dependents) eligible for or receiving premium subsidies through the FFM, and Medicare Supplement coverage.This policy does not apply to individuals enrolled in and receiving coverage under AccessTN as of January 1, 2016.
This policy, which is effective for health insurance coverage issued for the 2017 benefit year and thereafter, applies to individual health insurance coverage issued by BlueCross.This policy applies to Medicare Advantage insurance coverage issued for the 2018 benefit year and thereafter.
Acceptance of Premium Payments From Third Parties
BlueCross accepts and will continue to accept premium payments on behalf of a Member from organizations from which We are legally obligated to do so, such as the Ryan White HIV/AIDS Program. BlueCross reserves the right to request from such organizations confirmation as to the applicability of federal law to premium payments made by these organizations.
All other organizations that would like to make premium payments on behalf of a Member must apply for and receive approval from BlueCross in order for BlueCross to accept premium payments on behalf of Members from such organization. Applications to make premium payments for coverage for the 2017 benefit year will be accepted on and after November 14, 2016.
BlueCross’s approval of an organization’s application to make premium payments on behalf of a member is at BlueCross’s sole discretion and, if granted, is applicable for a single benefit year. An organization must re-apply each year for approval to make premium payments on behalf of Members so long as this policy remains in effect.
Application Process and Review Criteria
An organization(“Applicant”) interested in applying to make premium payments on behalf of a Member should contact BlueCross for the application and information regarding the application process. Although not an exhaustive description of the application process or review criteria, BlueCross offers potential Applicants the following information and guidelines:
- BlueCross will only accept applications from a non-profit charitable organization with an assistance program established prior to January 1, 2016.Consistent with CMS guidance, BlueCross will not accept applications or premium payments from “hospitals, other health care providers, and other commercial entities who may be considering supporting premium payments and cost-sharing obligations with respect to qualified health plans purchased by patients in the Marketplaces”.
- Each Applicant will be required to provide to BlueCross information regarding the Applicant and its assistance program, including, without limitation, the following:
- Description of the Applicant and its mission, history, and funding sources, including but not limited to funding for the assistance program;
- Description of the assistance program, including the target population, eligibility criteria(including criteria establishing financial need and how it will be measured), and program limitations ( i.e., funding limitations, enrollment limits);
- Identification of all funding sources for the Applicant (e.g., individual and corporate donors) and all funding sources for the assistance program.
- Description of planned outreach efforts and list of planned partner organizations for the assistance program;
- All Members who will be participating in the Applicant’s assistance program.
- BlueCross requires that an Applicant’s assistance program must reflect all of the following:
- An individual’s eligibility for participation in the Applicant’s assistance program must be based on an individual’s financial need, e.g. relative to the federal poverty guidelines.
- An individual’s eligibility for participation in the Applicant’s assistance program mustnot be conditioned upon or otherwise take into account the individual’s health status; manifestation of a specified condition, illness or disease; the individual’s relationship with a specific health care provider; the identity of any person who referred the individual to the Applicant or its assistance program; the identity of any donor to the Applicant or the value of any donation.
- An Applicant’s assistance program must maintain eligibility criteria for assistance as well as a process for screening potential candidates for assistance in accordance with such eligibility criteria and for verifying such candidates’ information. An individual’s eligibility for the assistance program is re-evaluated not less frequently than annually.
- An individual receiving support under an Applicant’s assistance program cannot be an employee or family member of the Applicant.
- BlueCross requires that an Applicant attest to the following:
- The Applicant does not advertise the availability of, nor solicit participation in, the Applicant’s assistance program at the site of a health care provider or any agency or organization that serves individuals based on their health status nor health care needs(e.g., a community agency that serves individuals who suffer from a specific medical condition).
- The Applicant does not limit or steer candidates for assistance toward specific health insurance coverage, including based on the issuer, the type of coverage, the metal-level of coverage (as applicable), benefit design, network type, or network participation of any specific health care provider(s).
- BlueCross requires that any non-profit, charitable organization for which BlueCross approves the application for making third-party premium payments (“Approved Charitable Organization”)
shall guarantee payment for the entire benefit year for each Member for whom the Approved Charitable Organization provides assistance.
- Premium payments must be made by the Approved Charitable Organization in full at the time due; partial payments will not be accepted by BlueCross.
- An Approved Charitable Organization shall submit payment of a premium on behalf of a Member in accordance with BlueCross’s payment policy.This includes, without limitation, submitting one payment per policy per month with the Member’s information included with the payment so that it can be posted to the correct account.
- Refunds for overpayments, rejected payments for non-approved organizations, terminations, etc., will be made payable to the funding source/payor BlueCross has on record or the member, as deemed appropriate by BlueCross.
BlueCross reserves the right to administer this policy in the manner BlueCross determines appropriate in its sole discretion, including, without limitation, limiting the number of Approved Charitable Organizations and/or Members participating in approved assistance program at any time and at BlueCross’ sole discretion and changing and/or discontinuing this policy at any time.
For more information regarding the policy or the application process, including to request an application, please contactThirdPartyPayor@BCBST.com.