John S. Linehan, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Baltimore and Washington, DC, offices, was featured in the first of a two-part video series in Managed Healthcare Executive, in “New Transparency Rules Mean Health Plans, PBMs Must Disclose Their Accumulators, Maximizer Programs,” with Peter Wehrwein and Briana Contreras.
Following is an excerpt:
Coupon accumulators have been controversial for many reasons, but one of them is the element of surprise. Plan members use coupons to cover their copays and out-of-pocket costs. The savings may be a huge relief, but members haven’t always realized that because their health plan or its PBM was using an accumulator, the value of the coupon not counting toward the deductible. The shock comes when the value of the coupon runs out.
“You could get all the way to May and June and you are getting a drug and everything is fine and, boom, you are hit with the deductible. If you can’t pay deductible, you are not getting coverage for that drug,” said John “Jack” S. Linehan, a lawyer at Epstein Becker Green, in an interview with Managed Healthcare Executive.®
The interview was accompanied by Linehan’s article “New state copay accumulators complicate the coupon compliance landscape,” which was posted on the MHE website this week.
Linehan … says the new transparency rules for health plans issued by CMS in October include a provision that, effectively, requires health plans and PBMs to disclose to their beneficiaries that they are using accumulators or maximizers.
Most large, sophisticated plans and PBMs already do, according to Linehan. Still, he said he sees the new rule as a significant step: “It does create, for the first time, a bright-line disclosure rule.”
“New plans, smaller plans, employer groups and so forth that are starting to use these mechanisms (accumulators and maximizers) should be on notice that they need to properly disclose that they are using these programs,” Linehan continued.
Linehan also sketched the federal government’s role in regulating accumulators and maximizers.
See also Part 2 of the interview: “Accumulator, Maximizer Regulation Picks Up at the State Level,” with Peter Wehrwein and Briana Contreras, in Managed Healthcare Executive.
Also see “New State Copay Accumulator Laws Complicate the Coupon Compliance Landscape,” by John S. Linehan, in Managed Healthcare Executive.