Comments to HHS re: Insurance Premium Cost-Sharing by the Ryan White Program

May 13, 2014

Marilyn Tavenner RN MHA
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Room 445-G, Hubert Humphrey Building
200 Independence Avenue SW
Washington, DC 20201

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

Dear Ms. Tavenner:

The Academy of Nutrition and Dietetics (the “Academy) appreciates the opportunity to submit comments to the Centers for Medicare and Medicaid Services (CMS) in response to the interim final rule published in the March 19, 2014 Federal Register. The Academy is the world’s largest organization of food and nutrition professionals, with more than 75,000 members comprised of registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists. We are committed to improving the nation’s health through food and nutrition and providing medical nutrition therapy (MNT)2 and other nutrition counseling services to meet the health needs of all citizens, including those with HIV infection. RDNs are integral components of the coordinated health care team through private insurance and at Ryan White HIV/AIDS Program funded centers across the nation at which low-income, uninsured, and under-insured individuals with HIV infection can get proper medical care.

The Academy strongly supports the proposed interim final rule ensuring that issuers of qualified health plans (QHPs) accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program (“Ryan White”), which provides HIV-related care and support services in the United States for individuals who do not have sufficient health care coverage or financial resources for coping with HIV disease; other Federal and State government programs that provide premium and cost sharing support for specific individuals; and Indian tribes, tribal organizations, and urban Indian organizations.

Payment from Ryan White and Other Programs

Payment for medical care for people living with HIV infection can come from several sources, depending on insurance coverage, enrollment in state and federal support programs, and other resources. Ryan White funds should be available not only to help pay premiums of health insurance plans and medication co-pays, but also pay for medical visit or laboratory co-payments. In addition, CMS should identify and publish where AIDS Drug Assistance Programs and Medicaid programs may provide for medically necessary nutrient supplementation. Further, Medicare and other funding sources may be available for nutrition-related care for diabetes, renal disease, and cardiovascular disease.

As the ACA is implemented and primary care is provided to people with HIV infection through an expanded Medicaid program or insurance procured through state marketplaces, the future of Ryan White—and therefore the ability of beneficiaries to receive comprehensive HIV/AIDS care—becomes uncertain. The Academy affirms that coverage under the ACA is not a substitute for Ryan White; Medicaid and private insurance in most states does not cover the unique food and nutrition services provided by Ryan White and many states have declined to expand Medicaid eligibility for their most needy citizens. As the Kaiser Family Foundation notes, Ryan White “will also likely continue to be important for many who gain new coverage, given that two-thirds of current Ryan White HIV/AIDS Program clients already have insurance.3

QHPs and Ryan White Provide Complementary Care

Although all citizens will now have access to primary care and essential health benefits through health insurance marketplaces, this does not include certain core medical and social services now covered by the Ryan White HIV/AIDS Treatment Modernization Act, such as nutrition services and MNT, access to nutrition experts, or oral health services. In addition, Ryan White ensures individuals with HIV infection receive medically necessary FNS and valuable medical case management services “to ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care”4 that are traditionally not available under state Medicaid programs or private, subsidized insurance available on state marketplaces. CMS should consider the ways in which nutrition services and medical nutrition therapy are coded and billed under a new coverage scheme to ensure these core medical services are provided when needed.

The Academy believes that the ACA and Ryan White both emphasize the importance and value of coordinated care and prevention and thus have the potential to complement one another if Ryan White is conscientiously reauthorized. Any changes impacting patients should be clearly communicated in advance; education about wellness benefits and primary care practice are critical. It is imperative to ensure that implementation of the ACA does not diminish the funding or effectiveness of Ryan White or the vital services provided to patients.

We appreciate the opportunity to offer comments regarding the Ryan White HIV/AIDS Program and QHP issuers. We are pleased to offer our assistance and expertise, including information from our Evidence Analysis Library (for which HRSA generously provided funding) in Ryan White’s assessment and reauthorization. Please contact either Jeanne Blankenship at 202/775-8277, ext. 6004 or by email at or Pepin Tuma at 202/775-8277, ext. 6001 or by email at with any questions or requests for additional information.

Jeanne Blankenship, MS, RDN Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
Academy of Nutrition and Dietetics

1 The Academy recently approved the optional use of the credential “registered dietitian nutritionist (RDN)” by “registered dietitians (RDs)” to more accurately convey who they are and what they do as the nation’s food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention. [Academy of Nutrition and Dietetics’ Definition of Terms list, Scope of Practice, accessed 31 June 2012.] The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.
3 “Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV,” Kaiser Family Foundation website at, accessed February 20, 2014.
4 Ryan White and Affordable Care Act Outreach, Enrollment and Benefits Counseling, HRSA Website at, accessed February 20, 2014.