Copay Accumulator Adjustment Programs:

Why They Are Increasing Costs to Patients and the Health Care System

The Problem: Copay Accumulator Adjustment Programs (CAAPs)

Patients with complex and chronic illnesses often rely on copay assistance programs to afford the specialty medications essential to their health. These funds from nonprofit organizations and manufacturers help patients afford their treatments—medications that rarely have generic alternatives. Visit AllCopaysCount.org

Increasingly, health insurance companies are using “copay accumulator adjustment programs” which exclude copay assistance payments from counting toward a patient’s annual deductible or out-of-pocket maximum. In effect, the insurer demands double payment of out-of-pocket costs: first from copay assistance and then again from patients.

What’s the story in Missouri?

Copay accumulator adjustment programs are on the rise. An analysis of the 2024 Missouri ACA plans found that CAAPs are present in 8 out of 9 plans. With CAAPs in place, patients can end up on the hook for out-of-pocket costs (up to the full amount of their out-of-pocket maximum, potentially as high as $10,600/person or $21,200/family in 2026). CAAPs also increase overall health care spending because patients cannot afford their prescribed preventative care and end up with advanced medical issues.

Policy Solution: Ensure All Copays Count

Missouri legislators can help patients afford critical treatments by ensuring all payments – made by or on behalf of patients – are counted toward the patients’ deductibles and out-of-pocket maximums:

• Patients should not be punished for utilizing copay assistance for treatments they need to control their complex and chronic conditions.
• So far, 25 states (AR, AZ, CO, CT, DE, GA, IA, IL, IN, KY, LA, MD, ME, NC, ND, NM, NY, OK, OR, TN, TX, VA, VT, WA, WV) DC, and Puerto Rico have protected patients by passing legislation to ensure all copays count. https://allcopayscount.org/
• All copays count legislation would protect Missouri patients by requiring insurers to count copay assistance payments toward patient deductibles and out-of-pocket maximums.

What Can You Do?