In early October, NHF joined members of The All Copays Count Coalition (ACCC), sending a letter signed by 73 leading patient advocacy and provider organizations, urging the Centers for Medicare & Medicaid Services to address copay accumulator adjustment policies in the 2024 Notice of Benefit and Payment Parameters. Revising this regulation would undo harmful health plan and pharmacy benefit manager (PBM) pricing practices and ensure patients receive the full benefit of copay assistance.
For patients with serious, chronic health conditions, including life-threatening illnesses, ongoing and continuous access to medication is essential. However, through Copay Accumulator Adjustmet Programs (CAAPs), health plans are able to pocket financial assistance meant to help patients with serious and chronic conditions afford their out-of-pocket costs. As a result, patients subject to CAAPs are often left without access to the medications they need.
The use of CAAPs increased exponentially following CMS’ adoption of CFR §156.130(h), which exempted manufacturer copay assistance from the Affordable Care Act (ACA)’s limits on cost-sharing, in direct conflict with the original legislation’s definition, which states: “Cost sharing means any expenditure required by or on behalf of an enrollee with respect to essential health benefits…” With 83 percent of commercial market enrollees now in plans that have an accumulator adjustment policy, vulnerable patients are left unable to benefit from assistance needed to access their medications.
“Clarifying that insurers must count any assistance paid by or on behalf of a patient toward their annual deductible and out-of-pocket limit is the simplest way to protect patient access to treatment and ensure that patients – rather than insurers – benefit from copay assistance,” said Kollet Koulianos, Vice President of Payer Relations at the National Hemophilia Foundation. “The All Copays Count Coalition and our diverse membership remain committed to working with policymakers on bipartisan solutions to protect vulnerable patients.”
To support action on this issue, the All Copays Count Coalition recently launched a new website designed to inform and engage the policy community on CAAPs and the harmful impact they have on patients with serious, chronic health conditions. The website contains numerous resources, including research, an interactive map of related state legislation, patient and advocate perspectives, and more. Learn more at www.AllCopaysCount.org.
The full text of the letter is available here.
About the All Copays Count Coalition:
The All Copays Count Coalition (ACCC) includes The AIDS Institute, the Arthritis Foundation, the Cancer Support Community, the Immune Deficiency Foundation, the National Hemophilia Foundation, the National Multiple Sclerosis Society, and more than 80 other groups serving the interests of patients with chronic and serious health conditions that rely on copay assistance in various forms to make medically necessary drug treatments affordable. Learn more at www.AllCopaysCount.org or connect with us on Facebook, Twitter and LinkedIn.
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Source: National Hemophilia Foundation, October 2022