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Federal rule allows health plans to discount manufacturer copay assistance.

On May 7, 2020, the U.S. Department of Health and Human Services finalized a rule that affects individuals who rely on patient copay assistance programs. The HHS rule (the “2021 Notice of Benefits and Payment Parameters,” or NBPP) allows health insurers to continue using accumulator adjusters for the coming plan year. This means that a health insurer can exclude manufacturer copay assistance amounts when calculating a patient’s overall deductible or out-of-pocket maximum. The upshot, for those whose health plans include an accumulator: much higher out-of-pocket costs and a serious barrier to access to care.

In comments submitted to HHS earlier this year, HFA and many other patient advocates stressed that manufacturer copay assistance programs serve as a critical lifeline for many people who live with chronic health conditions and rely on prescription medications. Just weeks ago, HFA and other members of the All Copays Count Coalition wrote again to HHS Secretary Azar, warning that copay accumulators present especially serious threats to access to care amid the ongoing COVID19 crisis. Unfortunately, HHS disregarded this input when the agency chose to finalize the NBPP’s accumulator adjuster provisions.

HFA and allied groups will continue to advocate for federal and state policies that prioritize patient access to their prescription medications. Notably, the NBPP specifically provides that state laws preserving the value of copay assistance for patients (as enacted last year in Virginia, West Virginia, Arizona, and Illinois) remain in effect for state-regulated health plans – so advocates plan to redouble their efforts at the state level.

In the meantime, we need to hear from you! If you learn that your copay assistance will no longer be credited toward your deductible or out-of-pocket maximum, please share your story with HFA’s Project CALLS. Collecting data on the impact of accumulators allows us to make a case for change when we ask lawmakers to take action to protect patients from these harmful health plan tactics.

Quick hits:

  • On May 13, HFA and 19 other patient and health advocacy groups filed an amicus curiae or friend of the court brief urging the U.S. Supreme Court to uphold the Affordable Care Act in the case of California v. Texas (previously Texas v. United States). The case is on appeal from lower court decisions invalidating (in whole or in part) the ACA. The twenty advocacy groups that signed onto the amicus brief describe the devastating impact that patients would face if the ACA is struck down.
  • The U.S. Congress began work on a fourth COVID relief package. On May 15, the House passed the HEROES Act (Health and Economic Recovery Omnibus Emergency Solutions), a $3 trillion bill that includes economic recovery provisions as well as additional health spending and insurance protections. In contrast to the relatively speedy, bipartisan passage of the first three federal COVID relief packages, however, the parties are divided over the contents and timing of a fourth COVID relief bill, with Senate Majority Leader Mitch McConnell announcing that he has no plans to take up the HEROES Act or any other stimulus package in the near term.
  • Colorado and Washington, two states that were on track to implement a public option in their state health insurance markets, both announced that they were delaying or scaling back those efforts as the states deal with budgetary impacts of the COVID19 pandemic.
  • On May 22, the Missouri Secretary of State certified that organizers had met the threshold to put Medicaid expansion on the ballot in Missouri. Missourians will vote in August whether to amend the state constitution to provide Medicaid coverage for low income adults pursuant to the terms of the ACA.
  • Governor Northam vetoed bills passed by the Virginia legislature that would have expanded the availability of “association health plans” within the state. Association health plans don’t have to meet important ACA standards; patient advocates oppose the expansion of these plans, warning that wider availability of AHPs would lead to customer confusion, destabilized risk pools, and more.
  • Five states (MD, NY, VT, MA, CA) and the District of Columbia continue to hold special enrollment periods open in their state ACA Marketplaces, responding to the COVID emergency. (Remember that, regardless of your state of residence, you may qualify for a 60-day special enrollment period if you’ve lost employer-based healthcare coverage, or if you’ve experienced other “qualifying life events” such as getting married/divorced, moving, giving birth/adopting a child, getting out of prison, turning 26, etc. You can find more information about navigating your health insurance options here.)



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