Healthcare Costs

2 minute read

Healthcare icon: grey heart with white cross insideOur Position

Access to the right medication at the right time is best decided between a consumer and their doctor. This is the main guiding principle for CTD when working on pharmaceutical policy issues, including access to medication, drug regulation and enforcement, and pharmaceutical research and development.

In 2021, we urged the Texas Legislature to step up and protect consumers from Copay Accumulators, a new insurance practice that raises individuals' healthcare costs. HB 2668 (Price) / SB 523 (Buckingham) would have ensured that health insurers apply ANY copayments toward a consumer’s deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum requirements under that consumer’s health plan. However, this bill did not pass.

Partners

Background

Texas has led the nation on important patient protections, but barriers still exist, including rising out-of-pocket costs for consumers. Health insurance deductibles have skyrocketed 111% since 2010, compared to a 19% rise in inflation. Particularly for Texans with complex chronic conditions or rare diseases, affording these out-of-pocket increases can be daunting, and many consumers rely on copay assistance programs. Through these programs, drug manufacturers or other third parties offer copay cards or coupons that help consumers to meet their insurer’s annual deductible and out-of-pocket requirements.

However, a growing number of insurers and Pharmacy Benefit Managers (PBMs) are implementing Accumulator Adjustment Programs or Copay Accumulators. When a consumer receives copay assistance, a Copay Accumulator prevents those funds from counting toward their annual deductible or other out-of-pocket requirements. This makes it harder for consumers to meet their deductible or maximum, resulting in higher out-of-pocket costs.

While continuing to accept the third-party copay assistance, a growing number of insurers and PBMs are no longer counting those payments toward the consumer’s required deductible or maximum. This means consumers continue to pay out of pocket throughout the year, as they work toward meeting their annual deductible or maximum. Rather than remaining stable and healthy, individuals who can’t afford to continue their treatment plan may experience unnecessary disease progression, hospitalizations, or life-threatening ramifications.

In addition, the language insurers use to describe these policies can be ambiguous and difficult to find. Consumers often unknowingly enroll in Copay Accumulator programs when accepting other benefits offered simultaneously.


Further Reading

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