If you get help on health insurance copays, you still might see a nasty bill surprise | Opinion [The Kansas City Star]

It’s no secret the past few years have been a struggle for many residents of our state, but I’m proud of the resilience of Kansans who keep pushing to adapt and innovate. We are all feeling the echoes of the pandemic and the ongoing inflation that has followed. It’s a shock to see the price increases in eggs, milk and many other items. That’s on top of the cost increases that we’ve come to expect for prescription drugs.

It’s become the norm to see prescription drug prices go up, but that doesn’t mean that we shouldn’t continue to look for ways to bring those costs down. People’s lives depend on it.

As the Kansas insurance commissioner from 2015 to 2019, I had the privilege of working every day to keep Kansans’ insurance costs more affordable and their access to lifesaving treatments readily available. One of my proudest achievements was working with insurers to provide coverage for the cost of 3D mammograms. We worked hard to increase awareness of insurance and address the many questions Kansans had regarding their plans. But as an uncle to twins born with cystic fibrosis, I know that there is still a lot of work to ensure that the health care needs of Kansans and all Americans are met.

Over the past 10 years, modern medicine has made incredible advancements in treating a wide range of life-threatening illnesses. But newer treatments can be effective only if the people who need them can get them — and the reality is that many families can’t afford to shoulder the cost by themselves.

Despite efforts by state and federal lawmakers to lower individuals’ health care costs, the 2023 out-of-pocket limit for Affordable Care Act plans can reach $9,100 per person and $18,200 for a family. This is far more than many chronically ill patients can afford year after year.

Pharmaceutical manufacturers, charities and nonprofits have created copay assistance programs to help fill that gap. This greatly reduces out-of-pocket payments for medication and treatment, making care more affordable for patients needing high-cost medications. Normally, contributions from these assistance programs would help offset the patient’s copay at the point of sale and would count toward fulfilling the patient’s out-of-pocket obligations. So, after several months of purchasing a high-cost specialty medication through a copay assistance program, a patient’s deductible would be fully met and the patient’s out-of-pocket costs would be more affordable.

However, many health insurance policies have what are known as copay accumulators, which allow insurers not to count the amounts of the patient’s copay that have been funded by third party assistance toward the patient’s out-of-pocket limits. So as a result, after patients have exhausted benefits from an assistance program, they are still left with copayment obligations.

Most people impacted don’t know that their health plan has a copay accumulator program until they go in for a test or scan to monitor their disease, and then are handed a surprise bill since they have not hit their annual out-of-pocket maximum.

Fortunately, the Help Ensure Lower Patient Copays Act was recently reintroduced in Congress after receiving bipartisan support last year. This act would update our federal laws to prohibit insurers and pharmacy benefit managers from continuing this practice and enable patients to access and afford the lifesaving medications they need to manage their chronic illnesses.

I ask you to please join me in urging members of Congress in all states to support the HELP Copays Act this year.

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