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Dear Addy,

I鈥檝e been hearing a lot about co-pay accumulator adjuster programs (CAAPs) lately. What are CAAPs, how do I know if my insurance plan has one, and what can I do about them?

Signed, Co-pay 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鈥檚 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).

You can also read more about CAAPs in our Policy Priorities CAAP One-Pager and in these Dear Addy posts from February 2019 and June 2018 (includes an infographic).

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鈥檚 frequently buried in plan documents that are hundreds of pages long.
  • CAAPs are often disguised with confusing and misleading names like 鈥渙ut-of-pocket protection programs鈥 or 鈥渟pecialty copay solutions鈥.
  • Plan documents sometimes say CAAPs 鈥渕ay鈥 be applied. In some cases, the accumulator language has been present for years without being enforced 鈥搕hen sprung on consumers with little notice.

If you have personal experience with CAAPs, HFA wants to hear from you! Please share your story with Project CALLS. Collecting data about the hardships caused by CAAPs is the only way to fight their implementation!

Why 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 鈥渄ouble-dipping鈥 when they keep cost-sharing assistance from the 3rd party while also collecting the full cost-sharing obligation from consumers.

Help Ensure Lower Patient Copays Act (HELP Copays Act) –聽H.R. 5801

H.R. 5801, a bill protecting patients from copay accumulator adjusters, was recently introduced on the federal level in the House of Representatives. H.R. 5801, the HELP Copays Act, is a two-part solution that:

  • clarifies the ACA definition of cost-sharing to ensure that payments made “by or on behalf of” patients count towards their deductibles and/or OOP maximums, and
  • closes the EHB loophole to ensure that any item or service covered by a health plan is considered part of the plan’s EHB package and thus cost-sharing for these items/services must be counted towards patients’ annual cost-sharing limits.

Join HFA in asking your legislators to support H.R. 5801 to protect patients from these harmful insurer practices and ensure that ALL COPAYS COUNT! Send an email to your officials and make a difference with just one click below:

CONNECT WITH YOUR LAWMAKERS TODAY!

Sincerely, Addy

Have a question? Email us. Your name will be changed in the response.HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed 鈥淒ear Addy.鈥 Questions submitted to this column are edited in order to protect your privacy and should be considered educational only, not individual guidance.


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