Court strikes down HHS rule allowing insurance companies not to count copay assistance

Court strikes down HHS rule allowing insurance companies not to count copay assistance

Washington, DC / ACCESSWIRE / October 2, 2023 / U.S. District Court Judge John D. Bates for the District of Columbia delivers a major victory for patients dependent on prescription drugs knocked down A federal rule from the Trump administration allows health insurers not to count copay assistance from drug manufacturers toward beneficiaries’ out-of-pocket costs.

this case Sued by U.S. Department of Health and Human Services HIV+ Hepatitis Policy Institute, Diabetes Leadership Council, Diabetes Patient Advocacy Alliance, Three patients relied on copay assistance and their insurance companies implemented a “copay accumulator” policy.

By using “copay accumulators,” health insurance companies pocket the copay assistance a patient receives instead of having it help patients pay for necessary medications. 2021 Notice of Benefits and Payment Parameters Rules enacted during the Trump administration authorize these practices. In its ruling, the court struck down the rule and acknowledged that it was illegal.

Insurers must now comply with 2020 federal rules for health plans. Under the rule, copay accumulators are only allowed for brand-name drugs with generic versions if allowed by state law. Federal regulations now prohibit insurers from implementing copay accumulators for drugs for which generic versions are unavailable.

“We are pleased that the court sided with patients who are struggling to afford their prescription drugs due to the greedy behavior of insurance companies and their PBMs,” he said. Carl Schmid, Executive Director of HIV+ Hepatitis Policy Institute. “We call on the Biden administration to implement this decision immediately and not take any further steps to undermine copay assistance that allows patients to access essential medications.”

“While this victory will certainly help millions of patients, it is regrettable that so many are forced to pay thousands of dollars in additional costs each year for prescription drugs, forcing us to take this legal action,” he said. George Huntley, CEO of Diabetes Leadership Council and Diabetes Patient Advocacy Alliance. “The Biden administration must now stand up for the American people and stop large insurance companies and their PBMs from depriving patients of all forms of support they receive when paying for critical medications.”

With high deductibles and cost-sharing, sometimes as much as 50% of a drug’s list price, patients rely on copay assistance to pay for their medications. According to IQVIA data, Last year, copay assistance totaled nearly $19 billion.

At the same time, insurance companies and PBMs are increasingly implementing out-of-pocket accumulators, which has a dramatic impact on patients who require high-cost prescription drugs, such as those with HIV, hepatitis, cancer, arthritis, diabetes, and Patients with multiple a Recent business plan surveys, Eighty-three percent of beneficiaries are enrolled in plans that use copay accumulators.

Despite the health insurance company’s claims, the court clearly explained that the copay accumulator increased the patient’s costs while increasing the insurance company’s profits. The court rejected the government’s claim by health insurance companies that drug company deductible assistance would reduce the cost of drugs that enrollees pay.

The court agreed with the plaintiffs that the rule was arbitrary and capricious because it allowed insurers to determine for themselves whether to include copay assistance within the definition of “cost sharing” based on conflicting interpretations of the same laws and regulations.

The court repeatedly rejected the government’s arguments and agreed that copay assistance would be required as part of “cost sharing,” based on arguments made by the plaintiffs because the statute provides that cost sharing is “or on behalf of the enrollee.” If U.S. Health & Public The Service sought further input on the legality of copay accumulators under the Affordable Care Act, which the court ultimately remanded to the U.S. Department of Health and Human Services.

Plaintiff thanks 29 patient groups for joint submissions Statement of Friends. They also thank Paul Hughes and Andrew Lyonsberg of McDermott Will & Emery LLP for representing them.

A link to the court’s opinion can be found here And the final order can be found at here.

All abstracts related to the case can be found here.


About the HIV+ Hepatitis Policy Institute
The HIV+ Hepatitis Policy Institute is a national nonprofit organization whose mission is to provide quality and affordable health care to people living with or at risk for HIV, hepatitis and other serious and chronic diseases.

About the Diabetes Leadership Council
The Diabetes Leadership Council is a 501(c)(3) patient advocacy organization composed of individuals with decades of diabetes experience and leadership dedicated to advancing patient-first policies at the local, state and national levels. We are people with diabetes, parents of children with diabetes, allies, and tireless volunteers dedicated to improving the lives of all those affected by diabetes. Our members, all former leaders of national diabetes organizations, work with policymakers and public and private sector influencers to call attention to the diabetes epidemic and give a voice to the 37 million people living with diabetes.

About the Diabetes Patient Advocacy Alliance
The Diabetes Patient Advocacy Coalition (DPAC), a 501(c)4 organization, is a grassroots coalition of thousands of people with diabetes, caregivers, patient advocates, health professionals, disease organizations and corporations who work together to promote and Support public policy initiatives to improve the health of people with diabetes.

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Doolin Hendrix

Jennifer Burke

source: HIV+ Hepatitis Policy Institute

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