States Act to Protect Consumers from Copay Accumulators

In a major victory for consumers, Kentucky, Oklahoma, and Arkansas enacted legislation this month to prevent health plans from pocketing the copay assistance that provides a critical lifeline to persons with bleeding disorders and other costly conditions.

Health plans鈥 use of harmful 鈥渃opay accumulator adjusters鈥 鈥 the practice addressed by the KY, OK, and AR bills 鈥 has exploded in recent years. Copay accumulators, according to one survey, now appear in over 75% of commercial health insurance plans. When a copay accumulator is in place, the insurer refuses to credit copay assistance dollars toward the consumer鈥檚 cost-sharing obligations. This can leave patients and their families in a life-threatening bind: pay the full cost-sharing for their medication (potentially up to $8,550 for an individual or $17,100 for a family!), or go without their medication.

With the April 2021 legislation, KY, OK, and AR join five other states (Arizona, Georgia, Illinois, Virginia, and West Virginia) and Puerto Rico, which previously passed laws to rein in accumulators and ensure that 鈥渁ll copays count.鈥 Some 20 other states are also considering similar bills this session. In Oregon, Connecticut, and Tennessee, accumulator prohibitions have passed at least one chamber with nearly unanimous support; comparable bills are advancing in Michigan, New York, and Ohio.

However, states can only regulate certain types of plans (individual, small group, and state employee coverage). Action by the federal government is needed to solve the problem of copay accumulators in self-funded large group health plans. HFA, as part of the All Copays Count coalition, continues to advocate for federal-level accumulator prohibitions.

Quick Hits:

  • President Biden in a national address on April 28th called on Congress to make permanent the recently-boosted tax credits that make Marketplace health plans more affordable. Other health-related elements in the Administration鈥檚 $1.8 trillion 鈥淎merican Families Plan鈥 include funding for home- and community-based services and for paid family and medical leave. While the President voiced support for some additional, more sweeping changes — allowing Medicare to negotiate drug prices, creating a public option, and lowering the age of eligibility for Medicare — he did not include those policies in the legislative package he unveiled on April 28th.
  • HFA joined with 123 other patient and provider organizations in an April 23rd sign-on letter to the Administration advocating for policies and protections that improve prescription drug affordability for the American people: cost-sharing caps for patients, first-dollar health plan coverage of prescription drugs, banning accumulator adjusters, and more. On Capitol Hill, House Democrats re-introduced H.R. 3, while Senator Wyden announced he would start work on a Senate drug pricing bill.
  • The Biden Administration continued to unwind Medicaid policies put in place by the previous administration. In April, the Centers for Medicare and Medicaid Services revoked approval for Medicaid work reporting requirements in Michigan and Wisconsin. CMS also rescinded the Trump Administration’s last-minute approval of Texas鈥 ten-year Medicaid managed care waiver. Texas (one of the 12 states that hasn鈥檛 expanded eligibility for its Medicaid program) had sought federal funding to support hospitals that provide care for uninsured patients. CMS鈥檚 rejection of that plan was widely seen as an effort to nudge Texas toward Medicaid expansion; however, on April 22, the Texas House of Representatives rejected a budget amendment that would have expanded Medicaid eligibility in the state.
  • On April 28th, the Missouri Senate voted against funding Medicaid expansion in the state鈥檚 budget. A voter-approved Medicaid expansion is supposed to go into effect on July 1, 2021, so the Senate鈥檚 refusal to provide funding for the program may land the issue before the courts.
  • In an effort to boost outreach and enrollment in ACA Marketplace plans, CMS announced that it will make $80 million available in grants to Navigators in the 36 federally-facilitated Marketplaces for the 2022 plan year. It is the largest annual allocation CMS has ever provided to Navigators (topping the $63 million awarded in 2016) and an eight-fold increase from 2020. Notably, 800,000 people have already signed up for ACA coverage since the COVID-related special enrollment period opened in February 2021.

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