| AIDS Institute
The AIDS Institute, part of the All Copays Count Coalition, has spent a lot of time searching health insurance plan documents to find co-pay accumulator policies and see if the plan is enforcing the policy.
To help consumers find and decipher these guidelines, the institute has put together this guide that explains where to find the language and what it means.
This information can be difficult for consumers to find. Insurers are not required to include deductibles in the summary of benefits and coverage, or to pass on full insurance documents during open enrollment. Even if the policy is included in the documents, the language can be ambiguous or confusing.
Buyers may need to call certain insurers to find out about co-pay accumulator policies. However, customer service representatives may not be able to answer accurately or be unavailable to buyers.
A study by the AIDS Institute found that the following health insurers in Ohio have added co-payment accumulators to their policies for 2021: Aultcare, Ambetter, BCBS, CareSource, Medical Mutual, Molina, Oscar Buckeye State Insurance Corp./Oscar Insurance Corp. of Ohio, Parent.
Steps to Find Co-Pay Accumulators in your insurance records
1. Find the relevant document. This can be a summary of the benefits and insurance cover, the benefit overview, the insurance certificate or a plan contract. Occasionally the information is in the formulary.
2. If an electronic copy of the plan documents is available, the easiest way to find the destination is to search for a keyword using these terms: manufacturer, third party, additional payment card, discount, discount or coupon.
3. If only a paper version of the document is available, look for keywords and phrases in the sections such as Co-Pay, Deductible, or Prescription Drug Benefits.
Language examples in the guidelines for adapting copayment accumulators
1. Certain prescription drug coupons, discounts, or assistance programs do not apply to your deductible or the maximum out of pocket.
2. The same applies if we discover that the payment for deductibles or co-payments has been made by a third party, e. B. a pharmaceutical manufacturer who pays for a drug in whole or in part, as a premium payment by third parties, which cannot be offset against your deductible or maximum out-of-pocket expenses.
3. If you participate in certain drug cost sharing programs offered by drug manufacturers or other third parties to reduce the cost sharing (copayment, co-insurance) you pay for certain specialty drugs, the reduced amount you pay may be the amount . We apply to your deductible and / or your expense limit if the specialty drug is provided by a network provider. Your eligibility to participate in such programs is subject to the programs’ terms and conditions, which are subject to change from time to time. We can discontinue the application of such reduced amounts to your share of the costs at any time.
4. The value of manufacturer vouchers applied to member co-payment may not apply to member deductibles or total spending limits. Information on manufacturer vouchers that apply to bar limits can be found on the Internet at [issuer website].
5. Some coupons do not count towards your maximum amount or your deductible. Some specialty drugs may qualify for third-party support programs that can lower your expenses on these products, subject to our prior approval. For those specialty medications that use third-party co-payment assistance, you will not receive a credit towards your maximum deductible or deductible for co-payments or co-insurance amounts that are applied to a manufacturer’s voucher or discount.
Interpret what you found in the fine print of your insurance policy
1. If the benefit does not apply to your deductible or your co-payment, the plan has a co-payment accumulator. This means that after your co-payment assistance expires, you will be asked to pay your co-payment in order to receive your prescription. If possible, continue shopping and select a plan that does not have this policy.
If you have no options without a co-payment accumulator, look for plans with separate prescription drug deductibles, lower co-insurance for specialty medications, or who apply co-pays and co-insurance before the deductible, as this may translate to lower expenses during the plan year.
2. If the plan uses ambiguous language, such as: B. “We cannot apply,” confirm the policy of the plan by calling a plan representative to see if your co-payment aid is considered.
3. If there is no language in the plan, it does not necessarily mean that the plan does not contain a co-payment accumulator. Remember that insurers do not need to post copayment accumulators in plan documents. Call a plan representative to confirm this.
Call to confirm a plan’s co-pay accumulator policy
1. Find the number for buyers listed in the benefits and insurance summary or on the insurer’s website.
2. Some plans do not use the term “co-payment accumulation”, so agents may be more receptive to general terms and conditions.
Sample script: “If I receive a manufacturer’s drug voucher or co-payment allowance to pay for my prescription at the pharmacy, will the amount that the co-payment allowance covers be counted towards my deductible or deductible?”
3. More tips:
a. Be persistent. The first person you speak to may not know the answer. You may have to wait on hold or speak to multiple agents before receiving a response.
b. It can be helpful to use the analogy of a gift card: customer service reps may be aware of other drug rebate programs that work differently than copayment and may not understand why you’re asking about the rebate that applies to the deductible. For example, “If my prescription is $ 100 and I have a co-pay card that pays $ 50 and I pay $ 50 out of pocket, what is the maximum that would be used for my excess or outlay become?”
c. If you are purchasing a custom plan from the Affordable Care Act 2021 market during the special enrollment period, see the AIDS Institute report for a complete list of plans in all states.
Stephanie Hengst is Manager, Policy & Research for the AIDS Institute in Washington, DC
source https://dailyhealthynews.ca/heres-how-to-check-your-health-insurance-policy-for-a-co-pay-accumulator/
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