CMS won't enforce its ACA copay accumulator plan in 2020

Woman paying for a prescription at a pharmacy
The Centers for Medicare & Medicaid Services will not enforce a plan to allow copay accumulators in Affordable Care Act plans. (Getty/Tom Merton)

The Trump administration will not enforce its copay accumulator policy for 2020 Affordable Care Act (ACA) plans amid confusion from stakeholders.

In April, the Centers for Medicare & Medicaid Services (CMS) finalized the annual rule governing the ACA plans including a provision that would block insurers from applying the value of drugmaker coupons to patients’ out-of-pocket limits when a generic drug is available.

In an FAQ document (PDF) posted earlier this week, CMS’ Center for Consumer Information and Insurance Oversight (CCIIO) said stakeholders warned that the rule was unclear on whether ACA exchange insurers would be required to apply the discounts to members’ out-of-pocket costs in other situations. 

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As such, CMS said it elected not to enforce the plan in 2020 after consulting with the Labor and Treasury departments. The agency said it would address the conflicts in rule-making for the 2021 plan year. 

RELATED: CMS seeking feedback on ways to address ACA exchange 'silver loading'

The agency added that it received feedback that the policy would conflict with regulation from the IRS governing high-deductible health plans (HDHPs), another cause for concern.

"The departments understand that the policy advanced by the 2020 [Notice of Benefit and Payment Parameters] and prior IRS guidance related to HDHPs may conflict, and therefore the departments’ interpretation of how drug manufacturers’ coupons apply with respect to the annual limitation on cost-sharing is ambiguous,” CMS wrote in the FAQ. 

CMS said in the FAQ that it would also not penalize states that declined to enforce the policy. 

Under a copay accumulator, drug manufacturers’ coupons cannot be applied to pay down deductibles or copayments, and they’re a growing tool for plans in the ACA markets as well as employer plans to shift additional costs to consumers. 

These are controversial among patient advocates and have been banned in some states including Virginia and West Virginia.   

RELATED: 60% of ACA exchange insurers plan to broaden participation in 2020—survey  

In response to the FAQ, the AIDS Institute called the reversal “disappointing.” The group had previously celebrated the policy as a big win, interpreting the rule as banning copay accumulators in situations where patients did not have access to generic alternatives. 

“Patients are complaining about high out-of-pocket costs for prescription drugs and rely on drug company copay assistance to afford them,” Carl Schmid, the institute’s deputy executive director, said in a statement.  

“CCIIO’s announcement is disappointing and will increase the cost patients must pay for their drugs, which is completely opposite of the administration’s desire to lower prescription drug costs for patients,” he said. 

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