Making All Copays Count is a Critical Tool in Patient Access to Care

Making sure patients can access and afford the medications that save lives and maintain a dignified quality of life is the singular goal of Patient Access Network Foundation’s programming and advocacy. The primary way patients interact with PAN Foundation is through programming aimed at funding the care needs of patients via grants or linkage to other funds, including covering the costs of transportation and food, if needed. The other work PAN Foundation does is directly aimed address the why the entity is needed in the first place: advocacy around health care policies directly addressing the high out-of-pocket costs of care and medication. To that end, squarely in the target for PAN Foundation’s 2022 agenda is tackling so-called “copay accumulator” programs enacted by private insurers, particularly pharmacy benefit managers, as a means of double dipping into the flow of funds and denying patients the maximal benefit of patient assistance programs.

The Hepatitis B Foundation defines a copay accumulator (or accumulator adjustment program) as "a strategy used by insurance companies and Pharmacy Benefits Managers (PBMs) that stop manufacturer copay assistance coupons from counting towards two things: 1) the deductible and 2) the maximum out-of-pocket spending." In years prior to copay accumulators as a practice, manufacturer copay assistance programs might issue a healthy benefit that would be applied to the out-of-pocket costs or deductibles a patient is required to pay their insurer. This resulted in the patient fanatical responsibility spending down based on the value of the patient assistance program (PAP), rather than the actual dollars spent by patients, extending affordability of accessing care and medications for patients. It was glorious, honestly. Let’s have a “back of the envelope” example:

Deductible: $1500
Out-of-Pocket Cap (In-Network): $3000
Co-pay: $150 per 30-day fill

Patient Assistance Program Benefit: $7500

Previously, a PAP would cover the initial deductible and all of the plan year’s co-pays while counting toward that maximum out-of-pocket cap all counted as something a patient paid into the plan. Now, insurers keep the entirety of the benefit and only count the $150 co-pay toward what a patient has paid into the plan. This process demands patients pay for those costs themselves and the insurer gets to keep all of that $7500 value from the PAP. Ultimately, this tactic increases patient costs.

PAN Foundation executive vice president, Amy Niles, argues “These discriminatory policies reduce access to critical and often life-saving prescription medications.” And she’s right.

Deductibles and co-pays are generally called “cost-sharing”, which is a bit of a misnomer because patients must pay the deductible before an insurer begins paying the benefits the plan offers. This means pre-deductible costs are not “shared” by anyone but patients. With only about 4 in 10 Americans with enough money in the bank to cover an unexpected expense of $1000 or more, one of the tactics insurers are using to minimize patients actually accessing care is by increasing deductibles. PAN Foundation polled adults and seniors on Medicare and found most couldn’t afford even $100 medical emergency. Advocates, myself included, argue insurers are seeking to limit patients even initiating care (or continuing pre-existing care from previous years) by making those initial payments due too expensive to afford in the first. Can’t get your meds if you can’t afford to see the provider prescribing them, right?

This level of insanity is firmly in the realm of the Centers for Medicare and Medicaid Services to regulate and, indeed, the previous administration issued a rule in 2020 that expressly allowed co-pay accumulators and the Biden administration sided with insurers over patients when it came to this same issue in 2021. Despite calls from advocates, the payment rules for 2023 (announced in 2022) do not address this abusive practice. Some states have introduced and even passed legislation that expressly requires some, but not all, insurers to apply the total value of PAPs to patient costs. However, no national law currently exists to prohibit co-pay accumulators.

All of this is why PAN Foundation and numerous other patient advocacy organizations have come together as members of the All Copays Count Coalition and are urging congress to pass H.R. 5801, the HELP Copays Act, which would require all additional payments, discounts, and other financial assistance be applied to the cost-sharing patients are expected to pay into a health care insurance plan.

If we’re to realize the maximum benefit of manufacturer patient assistance programs, family dollars being spent to help patients, and charitable foundation dollars are being appropriately applied in a fashion that maximizes patient access to care, we have to make all copays count.

PAN Foundation has even made it easy to take action today.

[Disclosure: Amy Niles, Executive Vice President of PAN Foundation is a long-standing board member for Community Access National Network]