All Copays Count Coalition
The All Copays Count Coalition works to make sure any copay help that a patient receives counts toward out-of-pocket costs. Copay accumulator programs are insurance practices that allow health plans and pharmacy benefit managers (PBMs) to exclude co-pay assistance from a patient’s deductible, which can lead to unexpected out-of-pocket costs when that assistance runs out. This matters because co-pay assistance helps people with chronic diseases afford their medicines, avoid surprise costs and stay on their treatment.
Policymakers can act in three main ways to protect patients from unfair copay policies. First, the Centers for Medicare & Medicaid Services (CMS) can update federal rules so that all copay assistance counts toward a patient’s out-of-pocket costs. Second, Congress can pass the HELP Copays Act to ensure patients get credit for all payments and close gaps in current law. Finally, states can continue passing their own laws to limit these practices, helping protect millions of patients while a nationwide solution is pursued.
Counting Copayment Assistance
The Arthritis Foundation is a founding member of the All Copays Count Coalition, a group of more than 80 patient and provider organizations working to protect access to affordable care for people with serious, chronic conditions. We advocate to ensure that all copay payments, whether made by patients or through assistance programs, count toward deductibles and out-of-pocket limits. This helps protect patients from unexpected costs and supports access to the medications they need. The following questions and answers explain how copay accumulator policies work and why this issue matters for patients.
How do copay accumulator programs impact patients?
Patients may use copay assistance for months without issue, but that assistance is not counted toward their deductible or out-of-pocket maximum. Once the assistance runs out, patients can suddenly face full prescription costs that they did not expect.
Why don't people know about copay accumulator programs when they choose a health plan?
Insurance companies are required to share plan details, but copay accumulator policies are often described using complex or confusing language. As a result, patients may not realize how these programs will affect their out-of-pocket costs until they are already enrolled in a plan.
What are the consequences for patients with chronic conditions?
When costs become unaffordable, many patients are forced to skip doses or stop taking their medications. This is especially challenging for people in high-deductible health plans, where lower premiums come with higher upfront costs for care and prescriptions.
Why does this issue matter for affordability and access to care?
Rising out-of-pocket costs and benefit designs that shift more costs to patients make it harder for people with chronic diseases to afford needed treatments. For many, these financial barriers directly interfere with staying on effective, ongoing care.
The Impact of Copay Accumulator Programs
Many patients do not realize that copay assistance may not count toward their deductible or out-of-pocket costs, leaving them with unexpected expenses when that support runs out. These added costs can force patients, especially those with chronic conditions, to delay or stop treatment altogether. Download the infographic below to see how these programs work and why ensuring all copays count is critical for patient access and affordability.
Unexpected Costs Can Disrupt Care
When Assistance Doesn't Count
Copay assistance can help patients afford medications, but some insurance plans do not count that support toward deductibles or out-of-pocket limits. This can leave patients unaware of their true costs until assistance runs out.
Download Graphic
Ways for Policymakers to Take Action
REGULATORY ACTION
Federally, the Centers for Medicare & Medicaid Services (CMS) can reverse the previous administration’s 2021 Notice of Benefit and Payment Parameters (NBPP) rule that allowed health insurance plans to adopt copay accumulator adjustment policies. This policy change is inconsistent with important financial protections promised by the Affordable Care Act, which defines cost-sharing as “any expenditure required by or on behalf of an enrollee with respect to essential health benefits…” (Section 1302(c)(3)). We urge CMS to enact these changes to protect patients.
On the state level, Minnesota and Nevada have issued regulatory guidance statewide restricting copay accumulator adjustment policies.
FEDERAL LEGISLATIVE ACTION
The Help Ensure Lower Patient Copays Act (HELP Copays Act) was created to stop the abusive practices of pharmacy benefit managers (PBMs) and health insurers. This bipartisan legislation would bring much-needed relief to financially vulnerable patients by ensuring that all payments — whether they come directly out of a patient’s pocket or with the help of copay assistance — count toward their out-of-pocket costs. This legislation would also close the essential health benefits loophole.
We encourage Congress to include the HELP Copays Act in any PBM reform package. This bill provides immediate financial relief to patients with serious, complex, chronic and rare diseases, a necessary component to any PBM reforms that come to the floor.
STATE LEGISLATIVE ACTION
Twenty-six states, the District of Columbia and Puerto Rico have already acted to protect patients by passing laws to ensure all copays count. States have authority to block accumulator adjustor policies in state exchanges and certain private health insurance plans. Although not all patients are protected by these laws and a federal solution is still needed, these state actions are helping millions of patients.
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