O AIDS Institute, part of All copays count coalition, spent significant time researching health insurance plan documents to find copay accumulation policies and determine if the plan is implementing the policy.
To help consumers find and decode these policies, the institute has produced this guide explaining where to find the language and what it means.
It can be difficult for consumers to find this information. Insurers are not required to include copay accumulator policies in the Summary of Benefits and Coverage, or to share all policy documents during open enrollment. Even if the policy is included in the documents, the language can be ambiguous or confusing.
Customers may need to call specific insurers to find out about any copay accumulator policies. However, customer service representatives may not be able to respond accurately or may not be available to buyers.
ONE to study by the AIDS Institute found the following Ohio Health Insurance included copay accumulators in its policies for 2021: Aultcare, Ambetter, BCBS, CareSource, Medical Mutual, Molina, Oscar Buckeye State Insurance Corp./Oscar Insurance Corp. of Ohio, Paramount.
Steps to find copay accumulators in your insurance plan documents
1. Locate the appropriate document. This could be a Summary of Benefits and Coverage, Schedule of Benefits, Proof of Coverage or a Plan Agreement. Occasionally, information is on the Form.
2. If an electronic copy of the plan documents is available, the easiest way to locate the offer is to do a keyword search for the words: manufacturer, third party, copay card, discount, rebate, or coupon.
3. If only a paper version of the document is available, search sections such as Cost Sharing, Deductibles, or Prescription Drug Benefits for keywords and phrases.
Examples of language in copay accumulator adjustment policies
1. Certain prescription drug coupons, discounts or assistance programs do not apply to your Deductible or Maximum Available.
2. Likewise, if we determine that the payment was made for deductibles or cost-sharing by a third party, such as a drug manufacturer paying for all or part of a drug, this will be considered a third-party premium payment that may not be accounted for for your deductible or maximum direct costs.
3. If you participate in certain drug Cost Sharing assistance programs offered by drug manufacturers or other third parties to reduce the Cost Sharing (Copay, Coinsurance) you pay for certain Special Drugs, the amount reduced what you pay may be the amount we apply to your deductible and/or out-of-pocket limit when the special drug is provided by a network provider. Your eligibility to participate in such programs depends on the programs’ applicable terms and conditions, which may be subject to change from time to time. We may stop applying such reduced amounts to your Cost Share at any time.
4. The value of any manufacturer coupon applied to member cost sharing may not apply to member deductibles or total outlay limits. You can find information about manufacturer coupons that apply to direct limits on the Internet at [issuer website].
5. Some coupons will not count towards the maximum amount or deductible you pay. Some specialty drugs may qualify for third-party copay assistance programs, which may reduce your direct costs for these products, subject to our prior approval. For any special drug where third-party copay assistance is used, you will not receive credit towards your Out-of-Pocket-Pocket or Deductible for any copay or coinsurance amounts that are applied to a coupon. manufacturer or discount.
interpreting what you found in the fine print of your insurance policy
1. If assistance does not apply to your deductible or maximum disbursed amount, the plan has a copay accumulator. This means that after your copayment ends, you must pay your deductible in full to receive your income. If possible, continue shopping and select a plan that does not have this policy.
If you have no options without a copay accumulator, look for plans with separate deductibles for prescription drugs, lower co-insurance for special-level drugs, or that apply co-pays and co-insurance before the deductible, as this can translate to lower direct costs during the year of the plan.
2. If the plan uses ambiguous language such as “We can’t apply”, confirm the plan’s policy by calling a plan representative to determine whether your copay assistance will be honored.
3. If there is no text in the plan, it does not necessarily mean that the plan does not include a copay accumulator. Remember that insurers do not need to post copay accumulators in plan documents. Call a plan representative to confirm.
Call to confirm a plan’s copay accumulator policy
1. Find the number of buyers listed in the Summary of Benefits and Coverage or on the insurer’s website.
2. Some plans do not use the term “copay accumulator policy”, so representatives may be more receptive to the general terms.
Script example: “If I receive a drug coupon from the manufacturer or assistance copay to help pay my prescription at the pharmacy, will the amount of assistance copay coverages count towards my deductible or outlay maximum?”
3. Other tips:
one. Be persistent. The first person you talk to may not know the answer. You may have to wait on hold or speak to multiple representatives before receiving an answer.
B. It can be helpful to use the gift card analogy: Customer service representatives may be familiar with other drug discount programs that work differently than copay assistance and may not understand why you’re asking about the drug count. discount for the franchise. Example: “If my receipt costs $100, and I have a copayment card that pays $50 and pays $50 out of pocket, how much would go towards my deductible or maximum disbursement limit?”
ç. If you are purchasing an individual plan on the 2021 Affordable Care Act Marketplace during the Special Enrollment Period, please check report for a complete review of plans in all states.
Stephanie Hengst is manager, policy and research at the AIDS Institute in Washington, D.C.