Lawmakers should restrict health insurance plan ‘co-pay accumulators’


At a time when access to health care and awareness of related disparities are at the forefront of our concerns, it makes sense to pass legislation in Connecticut that continues to allow residents to pay for treatments their doctors prescribe. . SB 1003 will do just that.

For many patients, treatment options for conditions like hemophilia and other chronic conditions are limited. Even for those with insurance, the costs passed on by insurance companies can put medications at an out-of-reach level of expense. Proposals like the ones we’ve seen from governors. Recently, Ned Lamont and Charlie Baker would do little to control the costs patients pay, but could stifle the research we depend on to advance the care and treatment we need.

On the other hand, legislation like SB 1003 has a direct impact on what patients spend out of pocket on life-saving treatments by allowing them to use co-payment assistance programs without incurring undue penalties. imposed by their insurance company and prohibiting the use of co-payment. accumulator programs in the state.

For years, pharmaceutical manufacturers have sought to help patients with out-of-pocket costs by offering co-payment assistance programs. How do they work? If you have a co-pay requirement for your medications of $100 and co-pay assistance of $50, you pay $50 and the manufacturer pays your insurance company $50 so you can have the medications. Until recently, all $100 would go towards your maximum disbursement or deductible.

Now, however, co-pay accumulator programs have changed that calculation.

Copay Accumulator Adjusters are a new cost-containment technique that has proliferated in recent years and are currently found in about 80% of commercial health plans. Accumulators can be difficult to spot because they are embedded in long, dense plan documents under many misleading names (such as “reimbursable protection programs” or “specialty co-pay solutions”). Their impact, however, is unmistakable. Insurers that incorporate accumulators into their health plans accept third-party assistance for a patient’s cost-sharing obligations, but then refuse to credit that assistance toward the patient’s annual deductible or maximum OOP limit. , often with little or no notice to the patient.

In the previous example, some people might be able to handle a moderate increase in their costs. However, for many more patients the difference is not $50, there could be thousands they are suddenly forced to pay or go without. necessary treatments.

Health plans say accumulators are needed to prevent third-party help from artificially inflating drug prices by tricking consumers into buying more expensive brand name products. However, this argument makes no sense for people with hemophilia or many other conditions for which no generic alternatives are available.

This argument is also contradicted by the fact that regimes do not simply refuse to accept help from third parties. Instead, health plans pocket third-party assistance — then “double up” by collecting the full cost-share amount from the patient again. Additionally, we understand that health insurance plans may not always apply accumulators consistently, but may discriminate against only those with costly conditions like hemophilia.

I urge lawmakers in Connecticut to follow the example of five states (Arizona, Georgia, Illinois, Virginia, and West Virginia) as well as Puerto Rico, which have already acted to restrict copay hoarders. In addition, recent research from the AIDS Institute found that copay accumulator coverages did not significantly increase premiums in Arizona or Virginia.

Accumulator programs are exceptionally harmful to people with high-cost diseases like hemophilia because they can require subscribers to pay their entire maximum outlay at the start of the calendar year with one of their first prescription fillings. Very few people can pay $8,550 up front (or $17,100 for families) to receive their monthly shipment of medications they rely on to prevent or treat bleeding episodes that could otherwise lead to severe joint damage or even death. Patients faced with such costs may decide they need to discontinue their regular treatment, or possibly turn to the emergency room for acute care, resulting in much higher short- and long-term treatment costs.

On behalf of Connecticut residents living with chronic disease, we urge lawmakers to support the passage of legislation that will have a real impact on patients, not stifle innovation. SB 1003 will ensure that patients are able to fully access the cost-sharing assistance available to them.

Richard Pezzillo is the executive director of the New England Hemophilia Association and chairs Patients for Prescription Access.


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