This latest insurer ‘surprise’ is galling

It's called a copay accumulator adjuster and states are outlawing it

IT’S SIMPLE; we pay our health insurance premiums and expect that in return our coverage will serve our best interests.  And yet, year after year it seems, we find new surprises that end up harming patients and boosting insurer profits higher than what they already are.

But the latest insurer “surprise” is particularly galling.  Even to those of us who have seen it all.

As co-leaders of a coalition of over 40 patient advocacy groups, we are strongly urging lawmakers to pass H1053 to stop insurers from literally double dipping, while leaving those they cover stuck with high out-of-pocket costs.

For thousands of Massachusetts residents, those out-of-pocket costs are the bane of their existence.  Many rely on copay assistance programs from third parties, drug manufacturers, advocacy groups etc. to help offset what they have to pay out of pocket.  It works like any gift card program.  You get a gift card, you buy something, and the amount of the gift card is applied to your purchase leaving you to pay for the remainder.

It used to be that the copay assistance plus what the patient had to pay were both counted toward satisfying a patient’s financial obligation.

But if you’re like many of the people we serve, you’ve seen a change.  Instead, more and more insurers are now implementing something called copay accumulator adjusters.  They take the assistance money from the third party but only apply the remainder—what the patient pays– towards meeting the patient’s deductible and out-of-pocket maximum.   The patient is left holding the bag, having to still meet his/her full out-of-pocket-maximum.

The only entity benefiting from the copay assistance is the insurer.

This puts a patient’s health at risk because he or she may decide to forgo the treatment or try to stretch it out to last longer, both of which will inevitably require more trips to the doctor’s office or even the emergency room.  We’ve heard from patients whose conditions have progressed because of this.  The accumulator adjuster programs also fly in the face of what insurance is supposed to do—namely help the patient cover medical expenses.

Insurers should not be able to get paid twice for providing one service.

This is happening all around the country, which is why more and more states are passing laws to prohibit it.  In fact, more than a dozen other states (including Connecticut and Maine) plus Puerto Rico have passed laws prohibiting insurers from doing this.  New York’s lawmakers did the same this year and that bill now awaits the governor’s signature.

Copay assistance, which is meant to help patients, should do just that. It should not go to insurers who are doubling down on their profits.

It’s our hope that Massachusetts lawmakers will see this health insurance practice for what it really is and take the necessary action to make sure their constituents are protected.

Richard Pezzillo is the executive director of the Dedham-based New England Hemophilia Association, which assists and advocates for patients with a bleeding disorder across New England. Bill Murphy is the director of advocacy and public policy for Epilepsy Foundation New England, which is based in Lowell.