State legislation can prevent harmful copay accumulator policies

In recent years, many health plans have implemented “copay accumulator adjustment policies” that are negatively impacting kidney and other chronic disease patients. Consumers and patients should be aware of this emerging change in insurance plans that hurt patients and add a new barrier to patients receiving care.

The copay accumulator practice prevents copayment assistance that helps patients pay for high-cost prescription drugs from counting towards their annual deductible or maximum out-of-pocket costs.

Because of these practices, kidney patients are facing rising out-of-pocket costs for the care they need. One way medication manufacturers help patients—particularly those with chronic, complex conditions like kidney disease—afford their medications is through copay assistance programs, where cards or coupons are given to help reduce the cost of care. Insurance companies are increasingly refusing to count this third-party assistance toward patient out-of-pocket requirements, which can result in patients arriving at the pharmacy counter and having to decide whether to pay hundreds or even thousands of dollars out of pocket, or not take their needed medicines.

The cost of prescription drugs is directly related to medication adherence—people are less likely to regularly take the medicines they are prescribed if the cost is a burden on their finances. Patients who are not able to afford their medicines face worsening health, disease progression and the potential for significantly increased health care costs. Dialysis patients, for example, must take a variety of medicines for the entire time they are on dialysis. People who are on dialysis take, on average, 19 pills a day to manage their kidney failure, as well as other underlying conditions like diabetes and high blood pressure.
 
Many patients and providers are unaware of these copay accumulator programs until they experience them and their medications are held hostage until they pay. These programs are often buried in the fine print of plans and require patients to spend thousands of dollars to reach their deductible or out-of-pocket maximum before they can get the care they need.

In May 2020, the U.S. Department of Health and Human Services issued a final federal Notice of Benefit and Payment Parameters (NBPP) for 2021 that contains several provisions, including a change related to cost-sharing for prescription drugs. The NBPP makes it clear that it is the responsibility of individual states to regulate copay accumulator adjustment programs.

Five states have so far successfully passed legislation that bans accumulator policies—Virginia, West Virginia, Illinois, Arizona and, most recently, Georgia—to help protect patients from high out-of-pocket costs. The American Kidney Fund (AKF) advocates vigorously for these policies at the state level because of the NBPP final rule. AKF has been working with state lawmakers, providers and patient organizations across the country to urge the passage of laws that ban copay accumulator policies. We intend to increase the number of states with these pro-patient laws rapidly, as we continue to advocate on behalf of kidney patients around the country. To accomplish this goal and advocate for patients, AKF is participating as a member of the All Copays Count Coalition steering committee and co-chairs its state-level subgroup of the coalition.

If you or a loved one has been negatively impacted by rising out-of-pocket health care costs due to these copay accumulator adjustment policies, please contact me—Lindsay Gill, AKF’s associate director of state policy and advocacy—at lgill@kidneyfund.org. We must fight together to demand that these bad policies are removed and replaced with good policies that allow patients and families to live their best lives.

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About the Author

Lindsay Gill

Lindsay Gill is an associate director of state policy and advocacy at the American Kidney Fund

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