Copay accumulators are harming patients

By Gwenesta Melton

Life is a challenge, but chronic health conditions can make daily living seem insurmountable. Diseases such as rheumatoid arthritis, asthma and inflammatory bowel disease often mean fatigue, recurring pain or general malaise for patients. Given many are already struggling, the last thing patients with chronic health conditions need is another barrier to accessing necessary, physician-prescribed medications. But recently, barriers to care only seem to be increasing.

One such barrier is copay accumulator programs, which are policies used by insurers to prevent payment assistance from coupons, rebates or other sources from counting toward a patient’s annual deductible and out-of-pocket maximum.

The problem is, instead of the assistance going to help patients, insurers collect that money and require patients to keep paying. This often leads to significant, unexpected and unfair out-of-pocket expenses. As a rheumatologist, I have seen numerous patients with chronic conditions who require medications for pain management, symptom mitigation and to maintain their quality of life. And there is no denying the consequences of copay accumulator practices disproportionately affect patients with chronic or severe conditions who already have lofty medical expenses – further harming our nation’s most vulnerable patients.

Although insurer copay accumulator policies may vary slightly from state to state, they all inevitably increase patient harm. In a DC Circuit Court decision last year, the proliferation of copay accumulators was banned—reversing a previous decision from 2020—however, policymakers must now act to enforce this rule.

The good news is that from Vermont to Oregon and everywhere in between, states are considering and passing accumulator bans, creating a welcome trend of prohibiting these oppressive policies. So far, 21 states have implemented copay accumulator bans, ensuring that any third-party payments, including manufacturer assistance, are applied to a patient’s deductible and out-of-pocket maximums. Other states have also focused on transparency and patient notification requirements, requiring insurers to clearly inform patients about the existence and impact of copay accumulator programs, ensuring patients are fully aware of how their copay assistance will be applied.

Nevada recently announced they are taking the fight against copay accumulators one step further. Starting in 2025, Nevada will be the first state to fully enforce the DC Court’s ruling by prohibiting all copay accumulator programs in health plans across the state. This mandate ensures that health plans in Nevada will not include accumulator policies, protecting patients from unfair and unexpected financial burdens.

Nevada’s decision to enforce the DC Circuit Court’s ruling through its Division of Insurance 2025 Health Benefit Plan Filing Guidance is a significant and encouraging step for the protection of patients. Other states must now follow that example and work to ban all copay accumulators. It is essential for states to act and protect our patients. Implementation at the federal level is feasible and needed to ensure all patients will be protected.

There is no denying the state-level action being taken to protect patients is encouraging, however, relying on only a patchwork of state legislation will leave patients across the country vulnerable. A uniform federal policy is also needed to ensure consistent protection for all patients across the country. Federal enforcement of the DC Circuit Court’s ruling is the only way to protect all patients from the financial burdens and access limitations created by copay accumulator programs.

Lawmakers should also introduce legislation that will ensure financial assistance from all sources benefits patients directly rather than line insurers' pockets. Furthermore, other states should follow Nevada’s example and enact their own copay accumulator bans to safeguard their residents. Across the country, advocacy groups, health care providers and patients must continue to push for these changes to ensure a fair and transparent healthcare system for all our patients.

Although challenges remain, I’m encouraged by the action states such as Nevada, are taking across the country to prohibit copay accumulator programs and focus on equitable, patient-centered treatment. By following their example, other states and the federal government can create comprehensive enforcement programs to reduce barriers and ensure all patients can access the medications they need and deserve.

Gwenesta Melton, MD, is rheumatologist based in North Carolina who serves as the vice president of the Association of Women in Rheumatology and Chair of the American College of Rheumatology's Affiliate Society Council. Contact her at [email protected].