Posted: October 16, 2020
Accumulator adjustment programs are a utilization management tool that prevent the value of co-pay assistance from applying to a patient’s deductible, leaving patients vulnerable to high out-of-pocket expenses when the value of their co-pay assistance runs out.
Patients using provider administered drugs have been relatively insulated from the programs to date, however, United Healthcare recently announced a new nationwide policy requiring prescribers to provide information on their patient’s use of co-pay assistance in conjunction with these drugs. The new requirements will be administratively burdensome for providers, but of even greater concern is how this information will be used to further expand the use of accumulator adjustment programs.
In their announcement of the new policy, United Healthcare indicated that it would use the new line of sight to medical side benefit co-pay assistance to apply accumulator adjustment programs. As a result, once the value of the assistance is exhausted patients may face untenable out-of-pocket costs that threaten their adherence to medically necessary therapies. While not all co-pay assistance serves to keep patients adherent on a medically necessary drug without suitable alternatives, accumulator programs have been indiscriminate in their attack on co-pay assistance. In all, rheumatologists should be aware that your patients with United Healthcare coverage may be exposed to significant additional expense moving forward.
The policy will apply across individual, fully insured group, and self-funded group health plans unless otherwise prohibited by state or federal law. Currently there are no conflicting federal statutes, but Arizona, Georgia, Illinois, Puerto Rico, Virginia, and West Virginia prohibit the use of accumulator adjustment programs to a degree for individual and fully insured group plans.
CSRO will continue to support legislation combatting the use of accumulator programs across the states and at the federal level. Patient stories will be a crucial component of highlighting the issue for legislators, and CSRO encourages providers to reach out to CSRO with these examples.
As the 2021 legislative sessions approach be sure to check the CSRO legislative map tool to stay up to date on opportunities to engage at the state and federal levels.