Cost-sharing refers to the portion of costs for healthcare services an enrollee of a health plan is responsible for paying out-of-pocket before the plan covers the remainder of the cost. Cost-sharing can be in the form of a deductible, copayment, coinsurance, or similar obligations. The out-of-pocket maximum is the maximum amount an enrollee must pay for covered services in a plan- year across all types of cost-sharing obligations. Under the Affordable Care Act, most plans have an out-of-pocket maximum that varies depending on if the plan is for an individual or a family.
Cost-sharing obligations for prescription drug coverage varies among health plans, with some plans providing coverage before the deductible, some requiring the enrollee to meet a plan deductible before providing coverage, and some requiring the enrollee to meet a specific prescription drug deductible.
Beginning January 1, 2023, when calculating an enrollee's contribution to any applicable cost-sharing requirement, a health carrier or health care benefit manager shall include any cost-sharing amounts paid by the enrollee directly or on behalf of the enrollee by another person for a covered prescription drug and apply that amount in full toward the enrollee's deductible, out-of-pocket maximum, or similar obligation.
The Insurance Commission may adopt any rules necessary to implement this requirement.
This requirement does not apply to a qualifying health plan for a health savings account to the extent necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under Internal Revenue Service laws, regulations, and guidance.
PRO: Pharmacy benefit managers reduce the amount they have to pay by not accepting manufacturer coupons and requiring the patient to pay more. Patients rely on coupons for high cost drugs and without better price regulation these coupons are essential. There are no cheaper alternatives for many chronic conditions without generic drug alternatives.
CON: Manufacturers use coupons to drive patients to higher cost drugs. This practice is not allowed in Medicare. There could be unintended consequence of higher premiums by requiring the coupons are counted toward cost-sharing. Coupons do not actually reduce the cost of drugs, and manufacturers could simply lower the cost of the drug to better help patients. Coupons reduces the use of cheaper generic drugs and drugs with coupons have a higher price growth rate.