As of summer 2023, nineteen states and one U.S. territory have enacted legislation to ban copay accumulator programs, ensuring that manufacturer-provided copay assistance counts towards a patient's deductible and out-of-pocket maximums. These legislative efforts aim to protect patients from unexpected healthcare costs and ensure that financial aid effectively reduces their financial burden.
States and Territories with Copay Accumulator Bans
The following states and one territory have banned copay accumulator programs:
| State/Territory |
|---|
| Arizona |
| Arkansas |
| Colorado |
| Connecticut |
| Delaware |
| Georgia |
| Illinois |
| Kentucky |
| Louisiana |
| Maine |
| New Mexico |
| New York |
| North Carolina |
| Oklahoma |
| Tennessee |
| Texas |
| Virginia |
| Washington |
| West Virginia |
| Puerto Rico |
Understanding Copay Accumulator Programs
Copay accumulator programs are clauses in health insurance plans that prevent manufacturer-provided copay assistance from counting towards a patient's deductible or out-of-pocket maximum. In essence, while the patient uses a coupon or copay card to pay for their medication, the health insurer does not recognize these payments as contributions from the patient. This means patients may exhaust their copay assistance much earlier in the year than anticipated and then suddenly face the full cost of their high-cost medications until they meet their deductible or out-of-pocket limit with their own funds.
Why States Ban Copay Accumulators
States have moved to ban copay accumulators primarily to safeguard patients, especially those managing chronic or rare diseases that require expensive medications. The rationale behind these bans includes:
- Ensuring Patient Benefit: Manufacturer copay assistance is intended to help patients afford their medications. Banning accumulators ensures this aid directly benefits the patient by contributing to their annual cost-sharing responsibilities.
- Preventing Surprise Costs: Patients can face unexpected and substantial costs once their copay assistance runs out, leading to treatment disruptions. Bans provide more predictable financial planning for patients.
- Promoting Treatment Adherence: By making medications more affordable throughout the year, these bans help ensure patients can consistently access and adhere to their prescribed treatments, leading to better health outcomes.
- Protecting Patient Choice: These laws reinforce the idea that financial assistance should support the patient, not reduce the insurer's liability at the patient's expense.
For more information on copay accumulator programs and how they affect patients, you can refer to resources from reputable patient advocacy organizations such as the Crohn's & Colitis Foundation.
