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Changes To Some ACA Plans Will Lead To Higher Prescription Costs

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

Consumers signing up for health insurance on the Affordable Care Act marketplace should double check how prescriptions are covered.

Advocates say some insurers are changing their plans and it could mean higher out-of-pocket costs for patients who depend on costly prescriptions.

The changes involve assistance programs from drug manufactures that patients use to help pay for high-price prescriptions. Insurance companies have traditionally allowed patients to count the payments towards their deductibles. 

But starting this year, some insurance plans are adopting copay accumulator adjustment programs, which prevent the assistance from being used to pay down deductibles and maximum out-of-pocket spending.

That means patients who depend on high-price drugs for diseases like AIDS and multiple sclerosis will end up paying thousands more, said Carl Schmid, deputy executive director of the AIDS Institute.

"We feel that people aren't going to pick up their drugs and not be adherent, which is dangerous to their health," Schmid said.

Health insurers are not being transparent about the change, so consumers may not be aware until they've already picked a plan, Schmid said.

“It’s really difficult for patients to find this information,” he said. “It’s in the plan contract. It’s not in the summary of benefits.”

The AIDS Institute researched insurance plan documents and called the major insurers on the Florida marketplace to determine if they were making changes. The Institute found that some plans offered by Florida Health Care, Molina and Health First contained copay accumulator adjustment programs.

Some plans offered by Florida Blue state that the company reserves the right not to apply copay assistance towards a beneficiary’s deductible. But a company spokeswoman said Florida Blue does not have a copay accumulator program and does not have plans to adopt one.  

The AIDS Institute sent letters to state Attorneys General and Insurance Commissioners throughout the country, asking them to investigate the health insurance changes.

Schmid worries that more insurance companies will begin adopting the plans in 2019, including employee insurance plans.

“Open enrollment is going to be starting in a couple months,” he said. “It’s important to let people know that they need to look at their plans. Don’t just look at the premiums.”

Julio Ochoa is editor of Health News Florida.