Agencies Propose Rules to Keep Copay Accumulators

Recently, CMS issued proposed regulations that, if finalized, will confirm that group health plans can exclude drug manufacturer coupons from out-of-pocket limits such as deductibles.

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Recently, CMS issued proposed regulations that, if finalized, will confirm that group health plans can exclude drug manufacturer coupons from out-of-pocket limits such as deductibles.

Last year, Centers for Medicare and Medicaid Services (CMS) regulations created some confusion as to whether group health plans could continue excluding prescription drug coupons from deductibles when there was no generic equivalent available. A subsequent FAQ offered temporary relief,  providing that group health plans with copay accumulators in place would not need to change accumulator features—at least with respect to deductibles and other out-of-pocket costs—through the 2020 plan year. The Business Group, along with other stakeholder organizations, engaged with CMS, the Department of Labor, and other regulatory entities to discuss the role copay accumulators play in controlling prescription drug costs and complying with IRS rules for health savings accounts and high-deductible health plans.

The welcome result is a proposal for the 2021 plan year and onward to:

  • Revise the current regulations to clarify that group plans and health insurance issuers have the flexibility to determine whether to include or exclude coupons from cost sharing (such as deductibles), regardless of whether a generic equivalent is available; and
  • Interpret “cost sharing” to exclude direct support from drug manufacturers for specific prescription drugs so that the value of coupons does not have to count toward a plan’s annual out-of-pocket limits.

CMS also notes that group health plans should:

  • Be transparent with plan participants about whether drug manufacturer coupons apply to out-of-pocket limits; and
  • Prominently include this information on websites and in brochures, plan summary documents and other materials that participants may use to select, plan, and understand their benefits.

What happens next?

CMS is accepting comments on the above proposals through March 2, 2020 and, after considering all comments, will issue final regulations—likely by this spring. The final regulations will establish the rules for copay accumulators and out-of-pocket limits for the 2021 plan year and onward. The Business Group will submit comments and welcomes input from members.

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