California leaders ignore health insurers’ latest scheme to make patients pay more | Opinion
My late father was born with hemophilia B, a hereditary bleeding disorder that requires regular infusions to control bleeding episodes. Infusions made life possible for him, but it was always a fight with the health insurance plan to get them covered. Seeing him in severe pain, as his insurer refused to cover a medically necessary treatment, drove me into the advocacy work I do today.
Legislators and regulators need to understand what patients go through every day to survive. Looking at the financial hardships alone, even with health insurance, many patients must hit certain cost-sharing amounts, like a deductible, before their insurer will start to cover their medical bills. Deductibles range from an average of
Californians living with hemophilia face treatment costs that may exceed
It’s no surprise that many patients struggling to afford critical care turn to financial assistance programs for help. These programs, offered by charitable organizations and pharmaceutical manufacturers, cover copays and other expenses for eligible patients for a limited time by making payments directly to the health plan on the patient’s behalf. Although insured patients shouldn’t have to rely on third parties to survive, I cannot overstate how critical these programs have become for those who live with complex conditions and are already struggling to make ends meet.
A 2021 survey found that 69% of those who depend on these financial assistance programs make less than
Unfortunately, as these assistance programs have become more widespread, health insurers and their Pharmacy Benefit Managers started to shift the costs back onto patients through something known as copay accumulator adjustment policies. In
By hiding copay accumulator adjustment policies within dense evidence of coverage documents, consumers are blindsided several months into the plan year when they discover that their financial assistance has run out but they still haven’t met their deductible. It’s not until the patient attempts to refill a prescription that they learn that their health insurer implemented a copay accumulator adjustment at the start of the year and none of the financial assistance counted toward their deductible.
This leaves surprised patients on the hook for thousands of dollars — if not more. Not only has the patient exhausted the financial assistance program, meaning they will no longer get help with copays, but they also are no closer to reaching their deductible, which puts them back at Step 1: paying out-of-pocket for everything despite the fact that they couldn’t afford it to begin with.
In response to this insurance and profit scheme coming to light, 20 states, plus
Although there is some movement at the federal level to ban copay accumulator adjustment policies nationwide with House Resolution 830, known as the HELP Copays Act, I’m disappointed that
When patients are unable to adhere to their treatment, they risk worsening their health — in some cases, irreversibly. We cannot expect to improve health outcomes and reduce the burden on the overall health care system without prohibiting anti-patient practices.
Navigating health insurance is complex enough. We can’t let patients continue to be put in the middle, forcing them to fight not only for their health but also to protect their pocketbooks. Patients deserve to receive the full benefit of their health insurance and financial assistance programs without facing roadblocks.
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