CMS to Allow Copay Accumulators, Cut Exchange User Fees

The CMS finalized a rule on Thursday that would allow health insurers to implement copay accumulator programs to prevent drug manufacturer coupons from applying to a patient’s annual limit on out-of-pocket costs in situations where a generic drug is available.

Last month, Virginia and West Virginia became the first states to ban such programs on the individual market. Another eight states are considering passing their own laws to ban copay accumulators, which patient advocates say limits access to medication.

The CMS, however, said the rule would encourage patients to use generic drugs and lower drug spending. It would apply to individual market, small group, large group and self-insured group health plans starting in 2020.

The agency is also moving ahead with plans to cut exchange user fees, which it said would result in lower premiums. The user fee would be lowered to 3% from 3.5% of premiums for qualified health plans sold on the federal exchange in 2020, while the rate would be lowered to 2.5% from 3.0% for plans sold on state-based exchanges.

“The rule issued today will give consumers immediate premium relief for 2020 by reducing the federal exchange user fees thanks to successful efforts to improve the efficiency of the exchange,” CMS Administrator Seema Verma said in the announcement. “At CMS we have improved the operations of the exchange to deliver a better consumer experience at a lower cost.”

The changes, first proposed in January, are part of the annual rule that sets the standards for insurers that will sell coverage on the ACA exchanges in 2020.

Also in the rule, the CMS said it is finalizing a proposal to change the methodology it uses to calculate how much subsidized exchange enrollees are required to contribute toward benchmark health plan premiums. Under the change, the required contribution percentage for 2020 slightly decreases to 8.24%.

The same change in methodology also increases the annual out-of-pocket maximum for people enrolled in individual and employer plans to $8,150 for single coverage and $16,300 for family coverage, representing a 3.2% increase over the 2019 limits.

The CMS finalized a number of provisions to improve the risk-adjustment data validation audits and provide insurers with more certainty. The agency also approved Alabama’s request to reduce risk-adjustment transfers for the small group market in 2020 by 50%.

It also finalized a new special enrollment period for people enrolled in an off-exchange individual insurance plan who experience a decrease in household income that makes them eligible for a premium tax credit on the exchanges.

The CMS said in the proposed rule that it supports ending the practice of “silver-loading” and asked stakeholders to comment on ways it might address silver-loading in future rules. It summarized those comments in the final rule and said it will take them into consideration in future policies, but is not finalizing anything related to silver-loading yet.


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