Many in the bleeding disorders community rely on patient copay assistance programs to help defray the out-of-pocket (OOP) cost of their prescription drugs. Unfortunately, health insurers increasingly are refusing to credit copay assistance toward patients’ deductibles and OOP maximums. Health plan policies called copay accumulator adjustments no longer count financial assistance toward the patient’s annual deductibles or their out-of-pocket maximum. In addition, a loophole in the Affordable Care Act allows many employer-sponsored health plans to deem certain critical and life-saving prescription drugs as “non-essential,” which significantly increases out-of-pocket costs for patients.
WHAT IS BEING DONE
To date, twelve states and one territory (AZ, AR, CT, GA, IL, KY, LA, NC, OK, PR, TN, VA, WV) have passed laws prohibiting or limiting the use of accumulator adjusters for all individual and small group plans.
On November 2, 2021 the Help Ensure Lower Patient Copays Act (HELP Copays Act), sponsored by Representatives Donald McEachin (D-VA), Rodney Davis (R-IL), Bonnie Watson Coleman (D-NJ), Bobby Rush (D-IL), Brian Fitzpatrick (R-PA), Yvette Clarke (D-NY), Marc Veasey (D-TX), Buddy Carter (R-GA), and Barbara Lee (D-CA) was introduced. The bipartisan HELP Copays Act (HR 5801) requires health plans to count the value of copay assistance toward patient cost-sharing requirements. This would bring much-needed relief to financially vulnerable patients by ensuring that all payments—whether they come directly out of a patient’s pocket or with the help of copay assistance—count towards their out-of-pocket costs.