My daughter, Delia, is one of the toughest people I know. Diagnosed with epilepsy when she was just a month old, she also lives with several other chronic diseases, and she beat cancer. As you can imagine, I’m very familiar with health insurance.
Our deductible is $2,500, which means none of the prescriptions will be paid for by my insurer until I pay that amount. My daughter’s prescription is $800 a month. There are no generic options right now, and no other medications work for her.
Out-of-pocket costs for patients relying on lifesaving medications can be steep to begin with, but increasingly, health insurers are adopting a new practice called a copay accumulator that is forcing patients to choose between filling their prescriptions and paying for other life necessities. A bill pending in Augusta, L.D. 1783, will ensure that all Maine patients can afford their treatments.
Here’s how accumulators work. I was given a prescription savings card for $750 from the pharmaceutical company to help pay for the prescription that month. That $750 from the drug company goes to the insurance company, and I have to pay only $50 for this month. But the insurance company doesn’t count that $750 toward my deductible, so when I go back the next month to get my daughter’s prescription, I must still meet my $2,500 deductible!
Think of it like this. You get a gift card to your favorite restaurant, and you go out to eat with your family. The bill comes to $75. You have a gift card for $50. You give it to the server and they return after applying it and tell you that the bill is still $75. The gift card you gave them went to the bill, but they aren’t applying that to your total bill. The restaurant is going to be paid twice: once with your gift card and once with you paying the total amount. Would you be OK with this? Probably not, right? This is what is happening with medications and the insurance companies. It’s immoral.
We pay our premiums, and any monetary assistance meant for patients should go to patients. Insurers should not be allowed to double-dip.
A 2022 report by The AIDS Institute should set off alarm bells. It shows that copay accumulators are found in the vast majority of commercial health plans.
In Maine, two-thirds to 99 percent of all plans include a copay accumulator. You might not know it because often it’s hidden in the fine print that you get after you have enrolled in the plan.
L.D. 1783 seeks to protect patients by forcing insurers to count the copay assistance toward your deducible, directly, and positively impacting patients needing life-saving treatments. No one should have to choose between filling a prescription or going without.
Insurers argue they use accumulators to rein in health care costs. But the AIDS Institute report also found that laws enacted to prevent copay accumulators did not increase health costs.
High out-of-pocket insurance costs are a deterrent to filling prescriptions. Research shows that when a patient is responsible for a $75-$125 copay, more than 40 percent walk away from the pharmacy.
Like in Delia’s situation, for many patients, such as those living with hepatitis C or AIDS, there are no alternative generic treatments. And even some generic medicines are still very expensive. Those living with chronic diseases such as epilepsy, multiple sclerosis, hemophilia, arthritis, cancer and many others often have limited treatment options.
Make no mistake: Insurers are using these programs to increase their profits while decreasing help to patients. It has nothing to do with reducing health care costs.
Fourteen states and Puerto Rico have already passed laws to protect against copay accumulators, and legislation is pending in several other states.
It’s my urgent hope that our lawmakers will pass L.D. 1783 without delay. It’s the right thing to do on many levels. And research shows us there’s no reason not to.
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