Time to close co-pay accumulator loophole

One of my primary goals is to advocate for Missouri families, as I believe future generations should be able to have the opportunity to grow up happy and healthy with the same opportunities that you and I have been able to take advantage of.

With the price of everything from eggs to automobiles going through the roof, I know that more and more hard-working families across this state are being asked to make some tough choices about what their budgets can accommodate. A choice they should never have to make is whether or not to get the health care their children need.

High-deductible health care plans like those available under Obamacare can impose significant economic stress on families, particularly if they have children with chronic diseases like cystic fibrosis, diabetes or cancer that can be costly to treat. In many cases, families in need can access co-pay assistance programs run by nonprofits and pharmaceutical manufacturers to help reduce out-of-pocket costs, paying for a large portion of expenses until their deductible is satisfied. These cost-sharing programs are something I absolutely support, as they help provide relief to Missouri families without getting government regulations in the way.

Unfortunately, starting in 2018, pharmacy benefit managers (PBMs) found a loophole to undermine these co-pay assistance programs and pass along more costs to consumers by declaring them "non-essential" and then using co-pay accumulator or co-pay maximizer clauses that allow them to exclude third-party payments from being applied toward patient deductibles. The "non-essential" designation is intended to prevent insurers from having to cover brand-name pharmaceuticals, but in 80% of cases covered by co-pay assistance programs there are simply no comparable generic options available.

Insurers and PBMs are using this loophole to saddle Missouri families with an ever-higher burden if they wish to receive care that improves their health and their quality of life. Unfortunately, many people do not realize their health coverage includes a co-pay accumulator clause until it is too late and they are told they have not satisfied their deductible. This is wrong, and it is time to close the co-pay accumulator loophole.

Nationwide, 16 states have passed laws to end this abuse, and a number of other states are considering similar legislation including right here in Missouri, where Rep. Dale Wright has sponsored HB442. There is also a bipartisan bill that would solve this issue nationally: the Help Ensure Lower Patient Copays Act, HR5801.

I truly hope that all of these measures pass, as consumers should be protected from unexpected medical bills and should not have to worry that co-pay assistance programs will wind up being nullified by co-pay accumulator clauses in their insurance policies.

Barry Hovis is the state representative for District 146 in the Missouri General Assembly.