CF Foundation Urges Full Implementation of Co-Pay Accumulator Ban in North Carolina

CF Foundation Urges Full Implementation of Co-Pay Accumulator Ban in North Carolina

In a letter to the North Carolina Department of Insurance, the Cystic Fibrosis Foundation urged the state to ensure the successful implementation of SB 257, which requires state-regulated insurers to apply third-party assistance to out-of-pocket maximums.

Nov. 18, 2024 | 5 min read

Dear Commissioner Causey:

On behalf of the more than 1,150 people in North Carolina living with cystic fibrosis, we write to bring your attention to legislation that was enacted in your state to prohibit copay accumulator adjustment programs. SB 257, which went into effect in 2021, requires state-regulated insurers to apply third-party assistance to out-of-pocket maximums and other patient cost-sharing requirements for drugs without generic equivalents, or for patients who have completed the plan’s prior authorization or review process for a brand name drug with a generic equivalent. SB 257 helps 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 enforces this important law. We recognize that monitoring plans for compliance is resource intensive and therefore, we wanted to let you know that we have found plans that do not appear to be in compliance with this law in your state. We request that the North Carolina Department of Insurance notify Oscar Health Plan that they are out of compliance.

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 SB 257
We applaud North Carolina 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 copay 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.

Marketplace plans being offered in North Carolina by Oscar Health Plan during this year’s open enrollment period specify that third-party payments will not apply to a patient’s cost-sharing obligations. We request that you reach out to Oscar to notify them that they are out of compliance and must update their 2025 plan documents immediately. Proactive communication with these plans will help ensure compliance with this law and that consumers have access to clear and accurate information about all plans during open enrollment. We also ask that you ensure that all carriers on offering Marketplace plans in North Carolina are in compliance with this law and clearly state that plans may only include copay accumulator programs for drugs with generic equivalents and when the patient has not completed step therapy or the plan’s prior authorization, exception, appeals, or review processes. Because SB 257 permits the use of accumulator programs in these instances, this has the potential to confuse consumers about when the law applies and to which drugs. As such, we ask that you thoroughly review submitted language to ensure that all plans’ documents, especially consumer-facing materials, make clear when third-party assistance will apply to a patient’s deductible, out-of-pocket maximums, and other cost-sharing obligations.

The Cystic Fibrosis Foundation is committed to supporting the successful implementation of SB 257 in North Carolina. Please consider us as a resource as you navigate this transition. Thank you for your help in ensuring North Carolinians have access to this important consumer protection.

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