Understanding Health Insurance Accumulators and Maximizers

Accumulators and maximizers are health care insurer programs that prevent patients from using drug manufacturer assistance to help satisfy patients’ out-of-pocket cost obligations, such as copayment and coinsurance costs. This overview provides information about these insurance company programs and how they may be affecting you and others you care about. Read on to understand more about:

• What are accumulator and maximizer programs?
• How do these programs affect patients?
• Have you been affected by a health insurer’s accumulator or maximizer program?

Background

For patients with autoimmune diseases and other serious and chronic conditions, affordable access to prescribed treatments can be extremely challenging, especially when health insurance plans impose significant cost-sharing obligations, such as high copayments and coinsurance. To help pay those significant out-of-pocket costs, patients rely on assistance from various sources, including charitable foundations, friends and family members, GoFundMe pages, or assistance from drug manufacturers. All of these types of assistance help patients afford the care and therapies that their health care providers have determined are medically necessary and appropriate to treat and manage their conditions.

But, since at least 2021, health insurance plans have claimed that they are permitted to disregard manufacturer assistance provided to patients in determining if patients have met their annual cost-sharing limits under federal law. When health insurance plans exclude manufacturer assistance provided to patients from counting toward patients’ annual out-of-pocket limits, patients are forced to pay more than the maximum amounts of annual cost-sharing that they are supposed to pay. Two examples of these types of practices are often referred to as “accumulator” programs and “maximizer” programs.

The Autoimmune Association is deeply concerned about these practices and the harm they cause to patients. We are actively advocating for changes to certain problematic federal regulations that we believe insurance plans are relying on when trying to justify these harmful practices. As part of those efforts, we are focused on raising awareness about these practices and identifying individuals who have been affected by them. We want to amplify the voices of patients and the patient community in advocating for change that will help improve access to treatments.

If you have been affected by an accumulator or maximizer program and would like to share your story, please contact us through this form. We are interested in hearing from you and learning about your experience.

What are accumulator and maximizer programs?

Accumulator and maximizer programs are schemes through which health plans accept patient assistance amounts provided by drug manufacturers on behalf of patients but then exclude those same amounts from the applicable limits on patients’ annual cost-sharing under their plans. These programs subject patients to annual cost-sharing obligations that often far exceed the amounts that are permitted by law and that are advertised in plan marketing materials. These programs also are typically not transparent to patients, such that patients frequently are surprised by them.

• With an accumulator program, a health plan identifies when a patient pays deductibles, copayments, or coinsurance on drugs by using a coupon or other financial assistance provided by a drug manufacturer. The accumulator system then prevents any of the amounts that the patient has paid using manufacturer assistance from counting toward the patient’s out-of-pocket obligations. This means that, when the manufacturer assistance for the product runs out or affected patients attempt to obtain other medicines or services, the patients find out that they must pay hundreds or even thousands of additional dollars to continue on the drug therapy or to obtain those other medicines or services.
• With a maximizer program, a health plan implements a scheme to exhaust 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. Maximizer programs take the maximum value of a manufacturer’s assistance for a year (e.g., $12,000) and apply that maximum throughout the plan year—either by distributing the maximum amount evenly (e.g., $1,000 per month), or by taking larger amounts early in the year and then tapering down in subsequent months—without allowing any of those amounts to count toward a patient’s annual deductible or cost-sharing limits under the plan. By spreading the value of the patient assistance over a full year, a maximizer program is designed to exhaust the patient assistance provided by the manufacturer, giving patients no credit toward their annual out-of-pocket obligations. As a result, the manufacturer assistance does not reduce the amount of patients’ deductibles and other cost-sharing obligations under the plan. Similar to accumulators, this means that, when the patient tries to obtain another health care item or service, the patient finds out that none of the payments made previously were counted toward the patient’s annual out-of-pocket maximum. The patient must then pay hundreds or even thousands of additional dollars to obtain those items/services.

How do these programs affect patients?

Accumulators and maximizers can dramatically increase and inflate patients’ cost-sharing obligations for prescribed treatments. As a result of these programs, patients are forced to pay additional cost-sharing payments over and above the maximum annual levels that are supposed to apply. Often, those amounts may run into the thousands or tens of thousands of dollars. Patients consequently face increased financial burdens and may be forced to delay or forgo necessary medical care because of the added financial burdens imposed on them.

Key indicators that a patient may be affected by an accumulator or maximizer program include, for example: (1) the patient suddenly faces a dramatically inflated copay cost (e.g., the copay increases from $150 to $8000); and (2) the patient is suddenly forced to use a specific specialty pharmacy. Additionally, in some instances, where all available copay assistance has been exhausted by the copay accumulator or maximizer program, the patient may be directed to seek alternative sources of copay assistance through charitable organizations—even though the patient pays for health insurance. This may result in delay and disruption of treatment.

Accumulator and maximizer programs, at their core, force patients to bear thousands of dollars in increased deductible, copayment, and coinsurance costs that should be satisfied by patient assistance programs. The health care consequences of shifting that significant additional burden onto patients can be devastating. Numerous studies show that patient abandonment of prescribed medication is a serious, potentially fatal problem and is associated with negative consequences related to poor health outcomes and progression of disease.

Have you been affected by a health insurer’s accumulator or maximizer program?

The Autoimmune Association is interested in hearing from you and learning about your experience so that you can be part of our efforts to stop accumulator and maximizer programs. Please complete this form. if you would like to share your experience with us. Your story can help us advocate for patients and the patient community as we work to change the federal policies that are allowing the use of these harmful programs.