Dear Addy: CAAP Clarification

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Dear Addy,

I keep hearing all about accumulator adjusters. Are those the same as copay accumulators? There are so many different terms that I get mixed up!


Copay Confused

Dear Co-Pay Confused,

Those are great questions. Co-pay accumulator adjuster programs (CAAPs) are becoming increasingly common in the bleeding disorders community, and they are complicated! What are copay accumulator adjuster programs? Copay accumulator adjuster programs (CAAPs) are a cost-containment tactic where insurers limit the extent to which patients can benefit from manufacturer copay assistance programs.

  • The insurer accepts manufacturer assistance BUT:
  • Does not credit any assistance towards patient’s deductible or annual OOP limit.
  • Draws down the full value of the assistance. Once that assistance is depleted, the patient is presented with a bill for the copay/coinsurance associated with their next prescription fill.
  • Patients end up on the hook for OOP costs up to the full amount of their OOP maximum ($8,700/person or $17,400/family in 2022).

Who is at risk of encountering a CAAP?

  • The use of CAAPs is spreading widely across the US insurance landscape. More than 80% of private plan consumers are getting hit with CAAPs (Avalere Health).
  • Every state has at least one Marketplace plan applying CAAPs. In 14 states, all Marketplace plans apply CAAPs.
  • CAAP language is hard to find, even for experts, and it’s frequently buried in plan documents that are hundreds of pages long.
  • CAAPs are often disguised with confusing and misleading names like “out-of-pocket protection programs” or “specialty copay solutions”.
  • Plan documents sometimes say CAAPs “may” be applied. In some cases, the accumulator language has been present for years without being enforced, then sprung on consumers with little notice.

If you have personal experience with CAAPs, share your story with Project CALLS. HFA collects data about the hardships caused by CAAPs to help with our advocacy efforts.

Why do we need protection against CAAPs?

  • Copay assistance is a lifeline for those with bleeding disorders, who cannot otherwise access the treatments they rely on to prevent permanent injury or death.
  • CAAPs are counterproductive because they shift costs to patients, discouraging adherence to treatment. Disruptions to treatment worse health and higher health spending all around.
  • Insurers are “double-dipping” when they keep cost-sharing assistance from the 3rd party while also collecting the full cost-sharing obligation from consumers.