Copay Accumulator Adjustor Programs (CAAPs) are a strategy used by insurers to redirect the value of manufacturer copay assistance – which is supposed to help patients afford their share of their drug costs – away from patients and toward the insurer’s own bottom line. But do they?
Readers of the Washington Wire will have noticed that the Hemophilia Federation of America (HFA) publishes a lot of posts about “copay accumulator adjuster programs” (CAAPs). This is a weedy but important topic! CAAPs are a strategy used by insurers to redirect the value of manufacturer copay assistance – which is supposed to help patients afford their share of their drug costs – away from patients and toward the insurer’s own bottom line. The insurer achieves this by accepting the manufacturer copay assistance but then refusing to credit those dollars toward the patient’s deductibles and out-of-pocket maximum. When the available copay assistance dollars are fully used up, the patient ends up facing a potentially unaffordable and unexpected bill for their next prescription refill. This leaves many in an untenable position: skip their refill, abandon their treatment plan, and/or turn to the ER for treatment of acute bleeding.
CAAPs are unfair, bad for patient health, and harmful to families’ financial security. Combating CAAPs is therefore a top priority for HFA and for many other patient organizations.
That battle is being waged on multiple fronts. HFA and allied patient groups are working to pass state-level laws that protect patients enrolled in ACA and small group coverage. We are advocating for the passage of H.R. 5801: federal legislation that would apply across all 50 states, requiring insurers (including self-funded plans) to count all copay amounts paid by or on behalf of an enrollee toward that individual’s OOP costs. And, in January 2022, HFA asked federal regulators to rein in CAAPs as part of our comments on the 2023 Notice of Benefit and Payment Parameters (NBPP), a set of proposed federal rules laying out ACA-related requirements for Marketplace and other health plans.
The 145-page NBPP covers a host of important topics – plan network adequacy, essential health benefits requirements, LGBTQ nondiscrimination, risk adjustment, and much more – but does not expressly address copay accumulator adjusters. HFA, in coalition comments, weighed in on many of the broad issues raised by the NBPP. In two separate comments (with the All Copays Counts Coalition, and in a joint HFA-NHF submission), HFA focused specifically on CAAPs, calling on regulators to prohibit this harmful and discriminatory practice.
Source: Hemophilia Federation of America