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Dear Stacey: Are There Costly Consequences to Co-Pay Accumulator Programs?

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Published on February 19, 2019

During this Dear Stacey segment, Patient Power founder Andrew Schorr is joined by noted health care attorney Stacey Worthy, from Aimed Alliance, to discuss new insurance policies that may affect cancer patients’ access to treatment. What is a co-pay accumulator? How is it impacting treatment affordability? Stacey explains why insurers are adopting a co-pay accumulator program, and how this policy threatens to shift the cost back to cancer patients who are on expensive therapies and use financial assistance. How can patients get involved? She also shares what people can do to encourage local representatives and employers to protect patients. Watch now to find out more about the “double-dip” deductible being introduced to some insurance plans.

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This is an Aimed Alliance program produced by Patient Power. We thank AbbVie for their support. Patient Power is solely responsible for program content.



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Transcript | Dear Stacey: Are There Costly Consequences to Co-Pay Accumulator Programs?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

Hello and welcome to Patient Power and another one of our ABCs of Patient Empowerment programs.  And with us is our partner and regular guest Stacey Worthy who is the counsel for the Aimed Alliance in Washington, DC and a noted healthcare attorney.  Stacey, welcome back. 

Stacey Worthy:

Thank you for having me. 

Andrew Schorr:

So, Stacey, let's put something on patients' radar.  Co-pay accumulator, what is it? 

Stacey Worthy:

So in order to explain what co-pay accumulators are I've got to give you a little bit of background about high-deductible health plans.  So typically if you're enrolled in a high-deductible health plan, this is one of those plans where your deductible could be in upwards of $6,000 per month.  If that's the case, then you have to use that deductible before your insurance really kicks in. 

So you could be paying $6,000 in one sitting if your drug, the retail drug, the retail price of that drug is in.  However, drug manufacturers offer what's called co-pay assistance, typically a coupon.  You get this coupon, it helps to cover the costs out of pocket.  Traditionally, those coupons have counted towards your deductible, so it kind of helps you spend that deductible down every month.  And then at some point that assistance might run out, but usually by that point you've met your deductible. 

With a co-pay accumulator program, the insurer prevents you from using that coupon, that assistance towards your deductible.  So all of a sudden. you might be trekking along with these coupons, run out of assistance, and then you get flooded with this $6,000 bill at the pharmacy, which is very problematic for most people. 

Andrew Schorr:

Well, it sounds like a rigged game, so—where you expect that, well, I'll have a certain amount of co-pays, but I'll reach some cap on that.  So here are foundations or drug manufacturers, could be others as well, providing assistance to help you with that co-pay, you're going to reach that cap and then your expense is limited.  And you're saying under these accumulator programs that may not happen. 

Stacey Worthy:

Exactly, yeah.  It's essentially a double dip where the insurer is getting the assistance that you've received, that coupon, and then on top of that they're getting the full deductible from you as well.  And it's also not the way that you traditionally think of coupons working.  So when you go to a grocery store and present a coupon to the cashier, the cashier at the grocery store doesn't get to keep that value, you do.  So it's just kind of exactly what you said, a rigged system where things aren't working out the way they should. 

Andrew Schorr:

Okay.  So we're at sort of a pivotal time now where the federal government, Department of Health and Human Services, is coming out with some procedures and recommendations.  In the meantime, the states are on different sides of this.  So tell us what could be happening, and let's tell patients and families maybe what they need to do. 

Stacey Worthy:

Absolutely.  HHS issued recently what's called a notice of benefit and payment parameters for '21, and that's basically suggestions on way—on some recommendations of what insurance plans should implement in the individual and small business exchanges.  So the ACA, market-based plan, sometimes called the Obamacare plan, and in this notice HHS, which is a federal department, federal health and human services, recommended that these exchange plans implement co-pay accumulator programs. 

Andrew Schorr:

So, okay.  So they're making this recommendation, and that does not sound good for our population.  Now, Patient Power largely reaches cancer patients, many of us, myself included now are on more expensive but breakthrough oral medicines where we have a co-pay.  So let's leave the Medicare audience aside.  I know I'm on Medicare, but for people who are not, maybe you have employer coverage or they've got individual coverage, you're talking about small businesses as well, individual plans.  There really is a big bull's eye on them related to these co-pay accumulators.  What should they do, either with their employer, or maybe at the state level is there something that can be done? 

Stacey Worthy:

Yeah, absolutely.  There's a couple of different things that can happen.  So in terms of this HHS notice, they can write to HHS.  They can submit a comment, and that comment period is rapidly approaching.  I think it's Tuesday February 18th, and so if you can't meet that deadline, because I know it is right around the corner, you can also write to your congress person and have them put pressure on HHS to change this notice to remove that recommendation about co-pay accumulators. 

Alternatively, a lot of states are starting to introduce legislation that would prohibit co-pay accumulators.  There are about eight states at this point that have introduced that kind of legislation.  So, again, you can call your state or local representative and tell them that you want this type of legislation to move toward to protect patients. 

And then if you're in an employer-sponsored plan you'll want to talk to your employer and encourage them not to adopt a co-pay accumulator.  If they feel like they really do need to adopt that kind of plan, then there's some guardrails that employers can put in place as well.  So they can offer more than one type of plan.  Perhaps one could be high deductible, one could be a traditional plan.  Or perhaps one plan would implement that co-pay accumulator and one would not.  So the employer does have some options. 

More importantly, we want to make sure that employees know what they're getting into, so very clear guidance on what these co-pay accumulators programs are.  A lot of times the language can be very misleading and confusing for the average consumer.  They just—they don't understand what the language is even talking about.  Sometimes it's couched as a benefit.  It implies that you're getting a benefit when it's actually a detriment in terms of what's going on with the co-pay accumulator.

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