Autoimmune Association Continues to Advocate to Protect Copay Assistance and Essential Health Benefits

The Autoimmune Association has shared comments with the office of Health and Human Services (HHS) regarding the 2026 Notice of Benefit and Payment Parameters (NBPP). Our comments were tailored to requesting the Centers for Medicare & Medicaid Services (CMS) to allow third-party assistance to apply patient’s annual cost-sharing limit and to protect essential health benefits (EHB).

In this proposed rule, CMS has failed to require that insurance companies must include any cost-sharing assistance towards a patient’s annual cost sharing limits. CMS has ignored a clear federal court ruling requiring inclusion of these amounts. Cost-sharing assistance from manufacturers, like other types of assistance, helps patients and their families cover their out-of-pocket costs for medicines. Permitting insurers to exclude this assistance from patients’ annual cost-sharing limitations is unfair to patients, and it undermines CMS’s important goals of improving access and affordability for patients–particularly for patients with serious and chronic conditions, including patients with autoimmune diseases. Patients should not be penalized for using the resources available to them to assist with that access.

In the 2025 NBPP final rule, we were thrilled CMS addressed insurance companies who were eliminating certain specialty medications from formularies and designating them as “non-essential health benefits” for individual and small group market plans. However, we would like to see these protections confirmed for large group and self-insured plans. Designating certain drugs as non-EHB creates serious medication access and affordability issues for patients with autoimmune diseases and other chronic conditions and is also inconsistent with applicable existing EHB regulations. Specialty medications are used to treat many chronic conditions, including autoimmune diseases like multiple sclerosis, rheumatoid arthritis, and psoriasis. Each autoimmune disease patient requires highly individualized care, with physicians personalizing each patient’s therapies and treatment plans. The different available treatments are not interchangeable, and patients on a medication regimen depend on uninterrupted access to their prescribed therapies.

We look forward to continuing to work with CMS on these important issues and continuing  to advocate for autoimmune patients. To read our full comment letter, please click here.

Additional Resources:

To learn more about copay accumulator and maximizer programs click here.

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Glossary of Terms

Accumulator Program — A tactic by insurance companies that prevents any of the amounts that the patient has paid using manufacturer assistance from counting toward the patient’s out-of-pocket costs.

Centers for Medicare & Medicaid Services (CMS) — A federal agency that administers the nation’s major healthcare programs including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

Copayment— A fixed amount you pay for a covered health care service after you’ve paid your deductible.

Department of Health and Human Services (HHS)– A Cabinet-level department of the federal government that aims to protect the health of all Americans and provides essential human services. HHS works to advance the sciences that support medicine, public health, and social services. HHS includes many sub-agencies, such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH).

Essential Health Benefits– A set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Some plans cover more services. Plans must offer dental coverage for children. Dental benefits for adults are optional.

Maximizer Program — A tactic by insurance companies that exhausts the maximum available patient assistance that a drug manufacturer offers to patients for prescription medicines and does so in a manner that does not count that assistance toward patients’ annual cost-sharing limits.

Out-of-pocket maximum/limit–The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.