Ensuring Copay Assistance Counts Toward Patient Out-of-Pocket Expenses

The All Copays Count Coalition is committed to ensuring financial assistance for copays contributes to patients' out-of-pocket expenses. Copay accumulator programs, used by health plans and pharmacy benefit managers (PBMs), often prevent this by excluding co-pay assistance from deductible calculations. This can lead to unexpected expenses and impact patients' access to necessary medications once assistance ends.

Various strategies are being explored to rectify this issue. The Centers for Medicare & Medicaid Services (CMS) could amend federal guidelines to include co-pay assistance in cost calculations. The legislative initiative, the HELP Copays Act, aims to ensure all payment sources, including copay assistance, contribute toward expenses, thereby closing legal loopholes. Additionally, states are implementing laws to curb these practices and safeguard patients, as work towards a national solution continues.

The Arthritis Foundation, part of the All Copays Count Coalition with over 80 organizations, advocates for including all copay payments in deductible calculations. This effort aims to protect patients from unexpected expenses and maintain their access to essential therapies.

The intricacies of copay accumulator policies can be difficult for enrollees to understand, often leaving them unaware of the financial impact until they face medication costs without assistance. This challenge is particularly significant for those with high-deductible plans, where initial costs are substantial even with lower premiums.

Rising out-of-pocket expenses, coupled with benefit designs passing more costs to consumers, significantly strain individuals needing ongoing treatment for chronic conditions. This financial pressure can force patients to reduce or cease medication usage.

Federally, the CMS has the potential to revise 2021 rules that allow insurers to apply copay accumulator policies, bolstering financial protections under the Affordable Care Act for cost-sharing. States like Minnesota and Nevada have already taken legislative steps to counter these policies.

The HELP Copays Act targets restrictive copay policies of PBMs and insurers, aiming for financial relief by counting all copays towards patient expenses. This legislation has bipartisan support and is a key element of broader PBM reform efforts. Currently, 26 states, along with the District of Columbia and Puerto Rico, have enacted laws ensuring copay contributions count towards patient costs, yet a unified federal approach is needed to fully address the issue.