Some relief ahead from accumulator adjusters. Finally some good news regarding accumulator adjusters! Patient advocates, including HFA, have been warning lawmakers that accumulator adjuster programs threaten access to care for people with chronic health conditions. In recent weeks, state and federal lawmakers signaled they have heard this message and took steps to rein in the use of these programs.
[As a reminder, accumulators are programs developed by insurers and pharmacy benefits managers that limit the value of manufacturer co-pay assistance to patients. When an accumulator is in place, an insurer accepts co-pay assistance for a patient’s out-of-pocket costs associated with a prescribed drugÂ but then doesn’t credit that amount toward the patient’s overall deductible or out-of-pocket (OOP) maximum. The insurer draws down the full value of the co-pay assistance; once the assistance is all used up, the patient is then on the hook for the next co-payment(s). As a result, patients with chronic and expensive disorders must personally pay deductibles, co-pays and other expenses up to their yearly OOP maximum, even as the health plan draws down the full amount of the co-pay card. This leaves people with bleeding disorders or other expensive conditions in a tough financial bind and can threaten their continued access to their prescription medications.]
In March and April, lawmakers in Virginia, West Virginia and Arizona enacted state legislation requiring insurers to credit all copayments – regardless of source – toward patient deductibles and out-of-pocket maximums. While the Arizona law is narrower than the versions passed by Virginia and West Virginia, all three of these states now afford protection to people with bleeding disorders who (a) are covered by state-regulated health plans, and (b) rely on manufacturer copay assistance. Similar bills are pending in a number of other states, including Illinois, Ohio and Pennsylvania, and advocates continue to work for passage of these measures.
More good news on accumulators arrived in April when the U.S. Centers for Medicare and Medicaid Services officially acknowledged that copay assistance programs play an important role for people who live with rare and costly conditions. CMS’s 2020 Notice of Benefit and Payment ParametersÂ spelled out new limits that will apply to accumulators, beginning next year. The NBPP says that health plans in 2020 will be permitted to exclude manufacturer copay assistance for a brand name drug from an individual’s OOP only when a generic alternative to the brand name drug is available.If no generic alternative exists, the NBPP states that manufacturer copay assistance payments must be credited toward the patient’s annual out-of-pocket maximum. (“Where there is no generic equivalent available,” CMS explains, “it is less likely that he manufacturer’s coupon would disincentivize a lower cost alternative and thereby distort the market.”) Since bleeding disorders treatments have no generic alternatives, copay assistance for these medications should be exempt from accumulator adjuster programs as of next year.
HFA and National Hemophilia Foundation filed joint comments on the NBPP when it was first proposed, and also joined in comments submitted by two different coalitions of patient advocates. HFA will monitor the implementation of the new federal policy regarding accumulators and will continue to defend access to treatments, care, and coverage.
- On April 1, 2019, HFA joined with 16 other patient groups to file an amicus curiae (“friend of the court”) brief in the appeal of Texas v. United States. The brief argues that affordable and accessible health care is essential in managing chronic disease; that the ACA improved access to health care for millions; and that the district court decision invalidating the ACA ignored Congress’s policy-based choice to preserve the health care law.
- On April 10, 2019, Congressmen Ruiz and Wenstrup introduced HR 2279, the Safe Step Act. This bill would place guardrails around the practice of step therapy. The legislation would require insurers to provide exceptions to their step therapy protocols in cases where a patient’s doctor determines that treatment with the health plan’s listed drug could jeopardize the patient’s health. About 20 states so far have enacted similar patient protection laws, but only federal legislation can protect individuals who are insured under self-funded, employer-provided health plans. HFA and a wide variety of other patient groups support HR 2279.
- On April 29, 2019, HFA wrote to the Mississippi Division of Medicaid, urging the state agency to reconsider its exclusion of many extensively used bleeding disorders medications from the agency’s preferred drug list.
- Legislatures are still in session in about 30 states. HFA continues to monitor and work with member orgs on a wide range of issues, including (in the Medicaid space) topics ranging from Medicaid expansion (NC, WI) to restrictions on eligibility and/or funding (e.g., AL, AK, FL, IA, MO, TN). HFA also continues to follow state-specific actions on other actions affecting insurance coverage, including creation of non-ACA-compliant plans (ID, KS); public option initiatives (CO, WA); and more.