Navigating copay accumulators in the health insurance maze
Eyeing the practice that negates some savings of treatment assistance cards
‘Tis that season again — not the one adorned with festive decorations and holiday cheer, but the one with the formidable task of selecting a health insurance plan from the marketplace at healthcare.gov. For those contending with hemophilia or other chronic health conditions, this annual ritual can be a precarious walk on a financial tightrope.
This year, copay accumulators have come to the forefront of my awareness. I’d heard the term, but it wasn’t until my 2023 plan had such a program that I realized how it affected my pocketbook. It’s no joke.
My home state of Florida, unfortunately, allows copay accumulators. That’s bad news for me.
My health plan
My 2023 plan, from Florida Blue, has a high-deductible Health Savings Account (HSA), which lets me set aside money on a pretax basis to pay for qualified medical expenses. Florida Blue is my county’s best option for a person with hemophilia, as it covers my medications.
However, the plan makes me confront sobering figures. A $6,800 yearly deductible accompanies my monthly premium of $565.61. While that’s undeniably a substantial financial commitment, being uninsured is even more daunting, considering the expenses involved with my hemophilia B and von Willebrand disease.
The two medications critical to my health bear a substantial price tag — over $7,000 per dose. And I frequently need multiple doses, given the nature of my bleeding disorders. Copay assistance cards from drug manufacturers and grants from the Pan Foundation alleviate some of my financial burden. But shockingly, my insurance company pocketed the copay assistance that I received this year.
How a copay accumulator works
Let’s look at my insurance plan, for example, with its annual $6,800 deductible. For simplicity, let’s say I also have a $5,000 copay assistance card or coupon that I’ll want to use to refill my medication, which we’ll say costs $5,000.
Without a copay accumulator, that $5,000 coupon will count toward my annual deductible. $6,800 — $5,000 = $1,800. I’m responsible for only that $1,800 to reach my deductible.
With a plan that has a copay accumulator, however, I lose money because the $5,000 coupon won’t count toward my deductible. $6,800 — $0 = $6,800. I have to pay the full $6,800 before satisfying my plan’s deductible.
Where does that coupon money, generally from the drug manufacturer, go instead? To my insurer. Meanwhile, I’m burdened with additional out-of-pocket expenses.
It’s a system that grants insurance companies the leeway to double-dip into my pocket, which I find unjust and counterintuitive.
The fight against the practice
According to The AIDS Institute, Arizona, Arkansas, Connecticut, Delaware, Georgia, Illinois, Kentucky, Louisiana, Maine, New York, North Carolina, Oklahoma, Puerto Rico, Tennessee, Virginia, Washington, and West Virginia prohibited copay accumulators on marketplace plans in 2023. That’s the good news for patients. The institute also has a “report card” for each state regarding its copay accumulators.
If you’d like to help stop this practice, you can email your legislators here to encourage them to support the HELP Copays Act. The National Bleeding Disorders Foundation collects recent developments on copay accumulators and the hemophilia community on its website.
Note: Hemophilia News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Hemophilia News Today or its parent company, BioNews, and are intended to spark discussion about issues pertaining to hemophilia.
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Comments
David Flannery
I have MS, not hemophilia, but came across this article because I am actively searching this topic. Copay Accumulators were found to be unlawful in the last days of September in Federal Court.https://www.goodwinlaw.com/en/insights/blogs/2023/10/federal-court-strikes-down-copay-accumulator-programs
Just last week, Health and Human Services announced that it will be appealing the court's decision - in other words, HHS wants to keep the language written in 2021 that allows insurers NOT to count copay assistance toward deductibles.
I have actively followed this issue as this was my first year dealing with the double-dipper insurance company practice.
Jennifer Lynne
Thank you, David, for your reply and the link to the article. None of this sounds good for the consumer, and I wonder how these rulings will affect individual state's decisions.