Accumulator insurance plan8/12/2023 Whereas CMS had not previously addressed whether plans had flexibility to implement copay accumulator programs, the 2020 NBPP Final Rule set forth a new subsection, 42 C.F.R. The 2021 NBPP Final Rule follows prior efforts to address accumulator activity under the Notice of Benefit and Payment Parameters for 2020 (“2020 NBPP Final Rule”), issued on April 25, 2019. CMS indicated that it may consider future rulemaking if plans fail to disclose copay accumulator programs (and, by extension, any accumulator elements included in copay maximizer programs) among other potential rulemaking. In the final rule, CMS provides that plans adopting such programs should apply them “in a uniform, non-discriminatory manner” and provide “clear and transparent” information to enrollees and potential enrollees. This policy makes it easier for group plans and issuers to adopt so-called “copay accumulator” programs, under which plans exclude the value of manufacturer copay assistance from counting toward an enrollee’s deductible or annual cost-sharing limit, as well as “copay maximizer” programs, under which plans align an enrollee’s copay obligation with available copay assistance from manufacturers and then apply manufacturer assistance to the enrollee’s copay obligation but not toward the enrollee’s deductible or annual cost-sharing limit. States could impose different requirements for fully insured plans. This policy applies to health plans sold on the ACA exchanges, as well as non-grandfathered individual and group health plans (including self-insured plans). The final rule, which will go into effect on July 13, 2020, expressly allows certain health plans to determine, to the extent permitted by state law, whether to count pharmaceutical manufacturer assistance with enrollee cost-sharing toward the plan’s annual limit on cost-sharing. On May 7, 2020, the Centers for Medicare & Medicaid Services (“CMS”) announced that it had finalized the Notice of Benefit and Payment Parameters for 2021 (“2021 NBPP Final Rule”). CMS Finalizes Rule Expressly Permitting Copay Accumulator Programs
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