Get rid of the copay accumulator

It's painful to watch the position patients are put in

HEALTH CARE PROFESSIONALS wake up every day with their patients’ wellbeing on their mind. Having worked in nursing for over 30 years, I know first-hand the personal pride we take in our work. Our primary concern is how to best treat patients, but unfortunately cost always lingered in the back of my mind – especially for new treatments deemed “non-essential” by insurance companies and their Pharmacy Benefit Managers. And in a field with quick moving innovation like medicine, sometimes cutting-edge drugs and treatments get that “non-essential” classification when they are anything but non-essential.

Cost should never be a factor for patients with lupus, cystic fibrosis, and other chronic and life-threatening illnesses. To help get patients the care they need, nonprofits and even some pharmaceutical companies themselves offer coupons, vouchers, and copay assistance programs. These give patients from all income levels the ability to access the most innovative treatments, but if the treatment is deemed non-essential, language in their health insurance plan that most people don’t even know exists called a “copay accumulator” may kick in. A copay accumulator is a mechanism that allows insurers and pharmacy benefit managers to not count the cost of assistance programs supporting “non-essential” medicine towards a patient’s out-of-pocket  maximum or deductible.

What does that mean in practice? Let’s say a patient has a $1,000 copay for a medicine but is enrolled in a manufacturer assistance program which covers $750 of the treatment. It would make sense for the entire $1,000 paid out by a combination of the assistance program and the patient to count toward their deductible and the maximum annual out-of-pocket cost.  But in a health insurance plan with a copay accumulator, payments made by someone other than the patient are excluded from the deductible and the annual maximum out-of-pocket cost. That means only the patient’s $250 counts toward the deductible and annual maximum out-of-pocket cost. In that scenario, the patient is forced to pay that $250 for each treatment, without ever hitting the maximum out-of-pocket cost. By labeling these medicines “non-essential,” health insurers pocket extra money and patients are left footing the bill. 

Speaking as a nurse, it is painful to put patients in a position where they need to balance whether they can afford medicine all because insurers are needlessly and cruelly separating out the source of payment. 

Here in Massachusetts both chambers had bills introduced last session to ensure patients are able to include any cost-=sharing amounts paid towards their deductible. Unfortunately, both of these bills were referred to study, effectively killing them. Likewise, Congress introduced bill H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act, but it too stalled despite bipartisan support.

We need to act now. The new Legislature here in Massachusetts has an opportunity to eliminate copay accumulator programs along with a governor like Maura Healey who has a history of standing up for consumers. I ask that lawmakers not wait to pass this vital fix, so patients can get the care they need and deserve. Please allow doctors and nurses to prescribe our patients medicines that give them the best results without them having to worry if they can afford them.

Heidi Koppelkam is a nurse at Brigham and Women’s Hospital focused on performance improvement and outcomes. Previously she worked as the clinical manager at Massachusetts Eye and Ear Hospital.