Dear Director Stolfi:
On behalf of the more than 450 people in Oregon living with cystic fibrosis, we write to bring your attention to legislation that was recently enacted in your state to prohibit copay accumulator adjustment programs. HB 4113 requires state-regulated insurers to apply third-party assistance to out-of-pocket maximums and other patient cost-sharing requirements starting January 1, 2025. This legislation marks a significant step forward to ensure access to essential treatments for individuals with chronic conditions like cystic fibrosis, and the CF Foundation stands ready to serve as a resource as your agency implements this important law. In preparation for open enrollment, we request that the Department of Consumer and Business Services notify all carriers offering health insurance plans on the Oregon Health Insurance Marketplace about this law and thoroughly review plan documents to ensure they do not include co-pay accumulator programs.
About Cystic Fibrosis
Cystic fibrosis is a progressive, genetic disease that affects the lungs, pancreas, and other organs. There are close to 40,000 children and adults living with cystic fibrosis in the United States, and CF can affect people of every racial and ethnic group. CF causes the body to produce thick, sticky mucus that clogs the lungs and digestive system, which can lead to life-threatening infections. Cystic fibrosis is both serious and progressive; lung damage caused by infection is irreversible and can have a lasting impact on length and quality of life. As a complex, multi-system condition, CF requires targeted, specialized treatment and medications. While advances in CF care are helping people live longer, healthier lives, we also know that the cost of care is a barrier to care for many people with the disease.
Implementation of HB 4113
We applaud Oregon for passing legislation to ban accumulator programs, but we are also mindful of the challenges that may arise during implementation, as we have seen instances of noncompliance from health plans in other states. For instance, in one state where an accumulator ban went into effect on January 1, 2024, we observed multiple marketplace plans’ evidence of coverage (EOC) stating that third-party assistance will not count toward a patient’s cost-sharing obligations. This led to confusion during open enrollment last year as people reviewed their plan options and left them unsure of whether their plan included a co-pay accumulator program. Plans informed the state’s insurance department that they had not updated their materials to reflect the recent policy change, but it is unacceptable to not provide patients with accurate information about their potential cost-sharing. Additionally, at least one of these plans continued to not apply third-party assistance to multiple patients’ cost-sharing obligations several months into 2024, leading to disruptions in patients’ access to vital therapies. The plan told us that they had not updated their internal systems to comply with the accumulator ban. All these examples highlight the need for increased oversight from regulators to ensure appropriate compliance with this policy.
Multiple plans offered on the Oregon Health Insurance Marketplace during last year’s open enrollment period specified that third-party payments will not apply to a patient’s cost-sharing obligations, including BridgeSpan Health Company, Moda Health Plan, PacificSource Health Plan, Providence Health Plan, and Regence BlueCross BlueShield of Oregon. These plans make up about 83% of marketplace plans offered in the state. As insurers prepare to submit plan language in preparation for the 2024 open enrollment period, we request that you inform all carriers of this newly passed legislation and state that including copay accumulator programs in state-regulated plans will be prohibited. We also ask that you thoroughly review submitted language to ensure that all plans’ documents, especially consumer-facing materials, make clear that third-party assistance will apply to a patient’s deductible, out-of-pocket maximums, and other cost-sharing obligations. Proactive communication with plans will help ensure compliance with this new law and that consumers have access to clear and accurate information about all plans when the open enrollment period begins on November 1, 2024.
The Cystic Fibrosis Foundation is committed to supporting the successful implementation of HB 4113 in Oregon. Please consider us as a resource as you navigate this transition. Thank you for your help in ensuring Oregonians have access to this important consumer protection.