Insurance companies must now count copay assistance from third parties toward deductibles and out-of-pocket costs, as a result of a recent move by the Department of Health and Human Services.
In January, HHS dropped its appeal of a 2020 federal court ruling on patient cost-sharing. The ruling prevents insurance companies from shifting health care costs on patients through a burdensome practice known as copay accumulators.
The Pulmonary Hypertension Association, which has been working for years to fight copay accumulations, praised the HHS decision. As part of the All Copays Count Coalition, PHA and 85 other patient organizations urge HHS to quickly enforce the rule and instruct insurers on how to comply.
“This is good news for people with pulmonary hypertension and others who rely on copay assistance to pay for expensive, life-saving medication,” said Katie Kroner, PHA’s vice president of advocacy and patient education. “Copay accumulators allowed insurance companies to profit from copay assistance meant to help patients without reducing patients’ financial burdens.”
Some pharmaceutical companies and charitable organizations offer financial assistance to help patients pay for expensive drugs, such as pulmonary hypertension treatments. However, in 2017, some health insurers began implementing copay accumulator adjustment policies.
The practice allowed beneficiaries to use third-party copay assistance, but prevented those payments from counting toward annual deductibles or out-of-pocket maximums. As a result, many people couldn’t reach their deductibles. When their copay assistance grants ran out, many people had to meet their full deductibles for the year. That made it nearly impossible for people with chronic health conditions like PH to afford their life-saving medications.
Patient advocacy groups sued HHS for permitting copay accumulator policies. In September 2023, a federal court in Washington, D.C., called the policies arbitrary and capricious and said they contradicted the intent of the law.
At least 20 states require insurers to apply payment assistance toward patient deductibles and out-of-pocket limits. Colleen Brunetti, immediate past chair of the PHA Board of Trustees, was among the patient advocates who helped end the cost-shifting practice in Connecticut.
PHA will work with the All Copays Count Coalition to distribute information to patients and health care providers on how to combat these now-illegal policies.
