Be on the Look-Out for “Accumulator Adjustment” Riders in Your Health Insurance

Consumers should be aware of an emerging change in insurance plans that is being referred to as “accumulator adjuster.” The issue is related to three aspects of insurance coverage.

  • Manufacturer Copay Card:  For expensive drugs that usually do not have a generic, manufacturers may offer a card to patients to help them pay for the drug. The patient presents the card to the pharmacy, and a portion of the patient’s cost of the drug is paid for by the manufacturer.
  • Deductible: The deductible of an insurance policy is the amount that the policy holder has to pay before the insurer covers more of the costs associated with health care services or pharmaceuticals. The costs “accumulate” until the policy holder reaches the deductible. Depending on the plan, a deductible could be anywhere from zero dollars to thousands of dollars. 
  • Copays and Coinsurance: Copays are set amount that the patient must pay. A copay for specific service or item is usually listed in the summary of benefits. Examples of copays can be $10.00 for a prescription or $25.00 for a doctor visit. Coinsurance is when the patient must pay a percentage of the cost. Hence, if the doctor charges $100, and the patient has a 20% copay, the patient must pay $20.  

In the last year, insurers have been changing their policy on allowing patients to use manufacturer copay cards to pay a portion of their deductible. Prior to the change, patients would use the manufacturer copay card as part of the costs that accumulate to reach the deductible. If the drugs are very expensive, patients could hit their deductible in the first few months of the year.

For example, if a patient has a $5,000 deductible and a manufacturer copay card worth $2,000, the patient would be responsible for paying $3,000.*

With the new policy, patients who had their drugs costs lowered by the manufacturer copay card, now must pay higher amounts.

For example, the same patient has a $5,000 deductible. The manufacturer copay card does not count as a way to accumulate costs to meet the deductible. The patient would be responsible for the full $5,000.*

It is hard to find this language in the policy, so consumers should read all documents. Language can include variations of “manufacturers coupons and copay cards are not included in cost-sharing or included in accumulation of costs of deductibles.”

Please keep in mind that some of these policies are being implemented midyear, so it is important to read any information that your insurance company sends to you.

The American Kidney Fund has signed onto to a letter to all state insurance commissioner offices to highlight the issue for insurance commissioners.

If you find that your policy now includes this accumulator adjuster change, it is important to file a complaint with your insurer and with your state department of insurance.

* The numbers provided are for use as an example. The numbers will change depending on the cost of the drug, the manufacturer copay card, and the insurance plan’s deductible.

Posted: | Author: AKF Staff