Health insurance companies have complained they are burdened with the high cost of diabetes care as a way to justify new programs that shift more of the cost of care to patients themselves. But these programs are actually padding profits in the insurance industry and placing a huge strain on diabetes patients already struggling to meet their health care needs.
Insurance companies are hiding this new effort behind opaque and confusing jargon. They call their new policies â€ścopay accumulators,â€ť â€śOut-of-Pocket Protection Programsâ€ť or â€śCoupon Adjustment: Benefit Plan Protection Programs.â€ť
These programs block patients from crediting a manufacturerâ€™s copay assistance â€” coupons or discount cards provided to patients to cover high copays on brand name and specialty drugs â€” toward the patientâ€™s annual deductibles.
Copay coupons have become a lifeline for many patients with diabetes, whose out-of-pocket costs for insulin have more than tripled in 15 years as the nationâ€™s largest pharmacy benefit managers (PBMs) refuse to cover more and more diabetes-related medications and supplies.
In fact, diabetes treatments have comprised as much as a quarter of the treatmentsÂ for any conditionÂ these PBMs have excluded from coverage over the past four years, more than any other treatment category, according to theÂ Doctor-Patient Rights Project.
Typically, insurers apply the entire value of a manufacturerâ€™s copay coupon to the patientâ€™s annual deductible, helping them meet it faster and at less cost. However, copay accumulator programs block patients from applying the coupon to their annual deductibles and out-of-pocket maximums, or require patients to expend all outside assistance before they will creditÂ anyÂ of the patientâ€™s actual out-of-pocket expenses to their deductibles.
Accumulator programs turn copay assistance into a ticking time bomb for diabetes patients. Patients use the coupons to pay almost nothing on their life-essential insulin and medications one month, only to get hit with the full, retail price of the insulin the next, when they have run out of copay assistance and may need to spend hundreds of dollars before they are eligible for their health planâ€™s full prescription drug benefit.
By making patients take longer to meet their annual deductibles, copay accumulators reduce the number of days each year that insurers are required to fully cover a patientâ€™s health-care expenses.
No wonder insurers continue to make record profits, even while their operating expenses are relatively flat. From 2016 to 2017, the top five insurance companies collected more thanÂ $5.8 billionÂ in earnings, roughly 38 percent more than the previous year. One insurerâ€™s income increased by a third. Anotherâ€™s more than doubled.
Meanwhile, the latest U.S. Census finds median household income is only $58,000, nearly one-third of which ($16,752) on average would be required to cover diabetes-related medical expenses, according to new research from the American Diabetes Association.
Patients should not be confused by health insurance jargon. Copay accumulator programs â€” by any name â€” exist solely to put profits before people and shift more of the annual cost of care toÂ patients, many of whom (like those treating diabetes and other chronic diseases) may require decades of treatment and are often incurable.
If the insurance company is just handing you more of the bill, what good is having health insurance? Patients should ask their health insurer how it will apply copay coupons to their annual deductible and demand to know where in their contract they agreed to let the insurance company change how they handle copay coupons mid-year.