What is a Co-Pay Accumulator Program?
What Is a Co-Pay Accumulator Program? from Patient Empowerment Network on Vimeo.
Joanna Morales, Esq, CEO of Triage Cancer describes a co-pay accumulator program and shares some states may have protections against such programs.
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Transcript
Diahanna Vallentine:
So, Joanna. What is a co-pay accumulator program? I’ve had patients ask me this question.
Joanna Morales:
So, a co-pay accumulator program is a program that insurance companies actually use to exclude the financial health that you’re getting to cover your out-of-pocket costs from counting against your deductibles or your out-of-pocket maximum. So this can actually be a huge problem for patients because it greatly increases their out-of-pocket costs. So imagine that you have an out-of-pocket maximum on your plan of $5000, and you have a prescription that costs $5000 for one month, which isn’t unheard of when we’re talking about the cost of cancer care, but you are able to actually get financial help to pay for $3000 of that cost, normally that financial help, which still counts towards your out-of-pocket maximum, so that would mean that you’ve met your out-of-pocket maximum of $5000 for the whole year. So you shouldn’t have to pay any other medical expenses out-of-pocket for the rest of that plan year, but with accumulator programs, the $3000 that you got financial help lift no longer count against your out-of-pocket maximum, and you actually have to face paying that $3000 in out-of-pocket expenses that you will have to pay during the year, so having to pay those additional costs out-of-pocket could greatly increase costs for patients and could potentially drive patients into debt or force them to stop taking their medications because they can’t afford to pay those out-of-pocket costs. Even though these co-pay accumulator programs are becoming more widespread, there are about 12 states now that have some protections around health insurance companies using co-pay accumulators, so this is actually an advocacy opportunity for the cancer community to take a look at how co-pay accumulators are being used by insurance companies.
Diahanna Vallentine:
So, when a state gives people opportunities to participate that going against their deductibles or their co-pays, then that person no longer has to worry about their insurance if they change insurance or the next year, ’cause all the insurance companies would be going by that law, that state law?
Joanna Morales:
Every state law is slightly different in how they handle copay accumulators, but generally, there are protections for consumers, so that insurance companies aren’t using copay accumulator programs to increase out-of-pocket cost for patients.
