The Success of Community Advocacy on Copay Assistance
February 13, 2024 – Over a decade ago, in response to outreach from patients and other stakeholders including Accessia Health, the government changed the law on coverage to end the practice of pre-existing condition discrimination to ensure patients with rare, chronic, and costly conditions have equitable access to coverage, care and therapies. Since that time, third-party payers have sought numerous innovations to increase and push out-of-pocket costs that jeopardize care, often in the name of ensuring patients pay their fair share.
One of the most pernicious tools that emerged in the private insurance market was the utilization of a copay accumulator/maximizer that did not count copayment assistance towards a patient’s out-of-pocket maximum.
Due to the disruption in care caused by copay accumulators and the hardship they imposed on those in need, the patient community and their supporting organizations pushed back. This campaign led to popular federal legislation in Congress, the HELP Copays Act (which seeks to broadly ban copay accumulators), and a lawsuit against the administration over proposed rules that explicitly encouraged the practice.
Recently, this lawsuit prevailed, and the administration has dropped all appeals! Now, copay accumulators cannot be used in many health plans or to calculate coverage costs.
Jennifer Noonan, Sr. Director of Compliance and Patient Programs at Accessia Health stated, “We are thrilled by this victory, which comes as a relief for individuals who have grappled with exorbitant out-of-pocket expenses due to copay accumulator and maximizer programs. These programs have made it impossible for some individuals to access life-saving treatments. The remarkable success of these efforts, led by patients and patient advocacy organizations, is a testament to the strength and impact of a united voice.”
What happens next?
- There is still a need for broader regulation. CMS and the government set rules for other payers. There is hope that the government will issue explicit guidance banning copay accumulators in a comprehensive way.
- Congressmen can pass the bipartisan HELP Copays Act to further restrict the practice. Many states have already banned the tool, but this would set another national standard.
- If you notice that any assistance is not going towards your health plan deductible, you can share the news of the court decision with your plan administrator and ask for a reversal. You can also report accumulator use to the Department of Labor (for employer provided insurance) and also report it to your state’s insurance commissioner.
This is a meaningful victory and an incremental step in the right direction, but there are many other issues disrupting patient access and increasing out-of-pocket costs. Accessia Health looks forward to collaborating with the community to continue ensuring your voice is heard and these issues are similarly corrected by policymakers.
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Prepared By Dane Christiansen, Health & Medicine Counsel Managing Partner