New comments outline ways to counteract cost-shifting insurance trends

We stand ready to work with this Administration to further the goal of lowering patient out-of-pocket costs.

Ashley CzinJanuary 28, 2022

New comments outline ways to counteract cost-shifting insurance trends.

PhRMA submitted comments this week in response to the Department of Health & Human Services’ (HHS) 2023 Notice of Benefit and Payment Parameters (NBPP) proposed rule. As outlined in our comments, PhRMA supports many of the policies in the proposed rule that would help improve the affordability of and access to health care, particularly among disadvantaged populations, including the following:

  • Requiring Qualified Health Plans to offer standardized benefit designs on Federally-Facilitated Exchanges (FFE) and State-Based Exchanges using the federal platform (SBE-FPs). Standardized plans can simplify health insurance enrollment by streamlining plan choices and making the shopping experience more patient friendly. They can also include lower cost sharing and designate some services eligible for coverage pre-deductible, increasing access to and affordability of care for patients.

  • Utilizing copayments, rather than coinsurance, for prescription drug tiers as part of the standardized plans for FFE and SBE-FP states. Coinsurance, which is often based on a medicine’s list price, can leave patients with unpredictable and unexpected out-of-pocket costs at the pharmacy counter — essentially a surprise medical bill — and may then lead to abandoned prescriptions, poor adherence and worse health outcomes. On the flip side, the use of fixed dollar copays gives predictability to the amount a patient will be asked to pay per prescription, per month and/or annually, leading to more predictable costs and better treatment adherence.

  • Advancing health equity for consumers purchasing Exchange coverage. Removing health insurance barriers to facilitate equal access to prescribed medicines, along with policies and practices to help drive durable, systemic change, are critical. In addition, addressing social determinants of health — including disparities in income, patient costs and barriers to access to care that are specific to a given community — is key to advancing health equity.

  • Proposing changes to Essential Health Benefits requirements, including establishing a more detailed definition of discriminatory benefit design. The Affordable Care Act’s nondiscrimination protections are particularly important in the context of prescription medicines, given the potential for insurer gaming based on a known need for specific medicines — often year after year — in the case of patients with certain health conditions. Although the 2023 NBPP proposal is a step in the right direction, PhRMA recommends HHS consider additional benefit design and plan practices that should be considered presumptively discriminatory.

While these proposals represent important progress for affordability and access, more needs to be done to counteract current trends in benefit design that are shifting more and more costs for medicines to patients and exacerbating health disparities. Namely, manufacturer cost-sharing assistance should count toward patients’ out-of-pocket maximums. In its 2021 NBPP rule, HHS arbitrarily finalized a change that allows commercial market health plans to exclude the value of manufacturer cost-sharing assistance from counting toward patients’ out-of-pocket maximums, a practice called accumulator adjustment programs.

Accumulator adjustment programs are a misguided tool health plans use to shift the cost of medicines to patients. They can substantially increase patients’ out-of-pocket costs, increasing financial burden and health risk, especially for those with serious and chronic illnesses who rely on cost-sharing assistance to access and afford their medicines. Allowing the use of accumulator adjustment programs is bad policy. HHS should reverse its policy from 2021 and replace it with the earlier finalized policy from the 2020 NBPP final rule.

We stand ready to work with this Administration to further the goal of lowering patient out-of-pocket costs.

Read the full comments here.

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