![]() Sources: Kaiser Family Foundation, “ Marketplace Enrollment, 2014–2023” Kaiser Family Foundation, “ Market Share and Enrollment of Largest Three Insurers – Large Group Market, 2019“ Kaiser Family Foundation, “ Market Share and Enrollment of Largest Three Insurers-Small Group Market, 2019“ AHIP, “ Health Coverage: State-to-State, 2023. Note: Puerto Rico has also implemented a copay accumulator ban these numbers do not account for non-Employee Retirement Income Security Act (ERISA) covered lives as part of this analysis. To receive Avalere updates, connect with us. With its hands-on policy experience from the payer, manufacturer, and third-party vendor perspectives, Avalere is well positioned to help your organization respond to-or shape-the evolving copay adjustment program landscape. Avalere OutlookĪvalere helps clients understand the evolving landscape of patient support, model the impacts of these policy changes, and identify solutions accounting for financial exposure while maximizing appropriate patient access. Puerto Rico has also enacted a copay accumulator ban. Note: State-level activity current as of June 21, 2023. Additional states may enact laws as they wrap up their 2023 state legislative sessions, increasing this number. As of January 1, 2024, at least 19% of the total US commercial market-26.46 million individuals-will be enrolled in plans that must count any form of copay assistance toward patient cost-sharing limits. These laws apply to state-regulated health plans, including the individual, fully insured large-group, and small-group markets. As of June 2023, 19 states have enacted laws banning payer and PBM use of copay accumulator programs. Through a number of amendments and weeks of discussion, the bill ended with a final House floor vote of 88 ayes, 1 nay, and 1 present not voting, and a final Senate floor vote of 28 ayes, 4 nays, and 1 present not voting. ![]() Over the past several years, state legislators have passed bills aimed at banning the use of copay accumulator programs and ensuring that any third-party copay assistance used by a patient is counted toward the cost-sharing limits of that patient’s plan. TPA worked with several organizations in the Patients for Access, Choice and Transparency Coalition to get this piece of legislation passed. Recent federal rulemaking provided guidance for plans and payers to use these programs in broader insurance markets (e.g., large/small group, exchange) while also introducing challenges, such as the need for manufacturers to ensure that their financial assistance is passed fully through to patients. Research has shown that more than 83% of commercial market enrollees belong to plans that have implemented copay accumulator programs, and 73% belong to plans that have implemented copay maximizer programs. Copay adjustment programs prevent this third-party assistance from counting toward patient’s deductibles and maximum out-of-pocket calculation as it otherwise would have without an adjustment program. Manufacturers often offer patient copay assistance programs to commercially insured patients to reduce their out-of-pocket drug costs. In recent years, payers and pharmacy benefit managers (PBMs) have increasingly used copay adjustment programs (i.e., copay accumulators and copay maximizers) to limit plan sponsor exposure to prescription drug costs. It was most recently updated on Jto include new information. While previous legislation in Maryland that allows co-pay assistance to count towards a patient’s out-of-pocket obligation was not successful, another attempt is being considered for 2023.Note: This insight was originally posted on May 13, 2022. Fourteen states and Puerto Rico have banned co-pay accumulator adjustment programs. The federal Notice of Benefit and Payment Parameters (NBPP) for 2021 made it clear that it is the responsibility of individual states to regulate copay accumulator adjustment programs. As of spring 2022, laws in 15 states and Puerto Rico address the use of copay adjustment programs by insurers or PBMs to help patients afford their. This means that patients who have cleared the UM protocols then face the challenge of paying for the high out-of-pocket medications prescribed by their provider. They are being used despite insurers and pharmacy benefit managers implementing utilization management (UM) protocols, such as prior authorization and step therapy, to ensure patients attempt lower-cost treatment alternatives first. Although health plans often use different terminology or slightly variable practices, all pose significant threats.Ĭopay accumulator adjustment programs can result in patients being left with very high out-of-pocket expenses to access their necessary medications. The use of “copay accumulator adjustment programs” prevents copayment assistance that helps patients pay for high-cost drugs from counting towards a member’s deductible or maximum out-of-pocket requirements. The MPS and many other Maryland organizations signed onto a letter to key Maryland legislators calling for copay accumulator reform in Maryland.
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