Most health plans across the country now include an opaque policy that prevents drug manufacturer coupons and copay assistance from counting against a plan's deductible or out-of-pocket limit, a trend patient advocates say is alarming and limits access to treatment.
"The money that is covered by copay assistance is still money that is being paid out and kept by the insurer for the plan," said Stephanie Hengst, manager of policy and research at The AIDS Institute.
Two-thirds of health insurance plans available in 32 states include a copay accumulator adjustment policy, according to a recent study by The AIDS Institute. In the 45 states that have not restricted the practice, at least one plan had a policy that said that any financial help a patient receives from a drug manufacturer, charity or other organization will not count toward their deductible, despite the insurance company continuing to pocket the total cost of the medication.
As the number of high-deductible plans rises, and drug costs soar, Hengst said these policies are particularly harmful to patients who suffer from chronic diseases that cannot substitute generic medications.
"Especially right now, when we're still navigating coronavirus pandemic, this just adds layers of hardship and barriers for people to maintain their health," said Hengst, who co-authored the study. "It's a tough thing to see."
Hengst said she first became aware of these policies in 2017, although it is hard to know exactly when health insurers first began enacting these programs because "health insurers and pharmacy benefits managers have been really sneaky, they haven't been well advertised as part of your insurance benefit design." The AIDS Institute looked at all the individual plans available on the Affordable Care Act exchanges in each state, reading their policy documents and, in some cases, calling customer service to figure out whether a copay adjustment accumulator policy was included. In seven states, no insurance company made any information about a copay adjustment accumulator policy available.
"The policy itself is really bad," Hengst said. "There's no way for patients to know about this and plan their healthcare budgets, without knowing that this exists in their plans. We've pushed for CMS to enforce more transparency on the issuers if they're going to do this."
Health insurance companies claim that copay accumulator adjustment policies incentivize consumers to seek out cheaper health options and help health insurance companies lobby for lower drug prices for enrollees. A spokesman for America's Health Insurance Plans pointed to a March 2020 letter the lobbying group sent to then-CMS Administrator Seema Verma, which said that by helping consumers pay for the cost of their medications, drug companies steer patients and physicians toward more expensive, brand-name treatments. It blamed copay assistance for obscuring and increasing treatment costs.
"Coupons make the true cost of a drug essentially unknowable to consumers and physicians," the letter reads. "Meanwhile, health insurance providers are left to foot the bill for the entire treatment cost, which gets passed on to consumers, employers and the taxpayers."
Recently, insurers' copay accumulator adjustment policies have caught the eye of regulators.
In April 2019, CMS proposed a rule limiting the use of copay adjustment policies. But the following year, in May, the agency then reversed its stance in the final rule, allowing insurers to decide whether to include them in policy guidelines. Hengst said the federal attention ultimately encouraged more insurers to take up the policies as smaller plans learned about the practice.
"As these gain notoriety, other issuers became more aware of them from the other big issuers that are already instituting these policies," Hengst said. "They're like, 'Oh, Blue Cross and Blue Shield, Molina, those bigger issuers are already doing this. This is a way for us to also make money."
While the AIDS Institute study focused on individual plans on the exchange, the report noted the practice is also becoming more common among employer-sponsored coverage. It referenced a 2019 survey of large employers that found 34% were using copay accumulator adjustment policies, and that an additional 4% planned on adding them in the next year.
Hengst said this was particularly concerning since most of these plans do not have to follow state insurance laws. Even in the five states that have banned copay accumulator programs, residents may still be enrolled in health insurance plans that have such programs. Hengst said this underscores the need for federal attention to the matter.
"As the Biden administration continues to strengthen the ACA, we hope bans on copay accumulator programs could be incorporated into that," she said.