Provisions in CMS Proposed Rule on Drug Manufacturer Coupons, Automatic Re-enrollment Could Erode Access to Cancer Care

March 3, 2020

In a letter to the Centers for Medicare & Medicaid Services (CMS), the Association for Clinical Oncology (ASCO) expressed concerns regarding two provisions in the 2021 Affordable Care Act (ACA) Notice of Benefit and Payment Parameters proposed rule. This proposal, if implemented, would update the regulatory and financial standards applied to ACA Exchanges. ASCO is concerned that the exclusion of drug manufacturer coupons from the annual limitation on beneficiary cost sharing and automatic re-enrollment without advanced premium tax credits (APTCs) could erode access to affordable care for people with cancer.

Under the provision on drug manufacturer coupons, payers would have the sole ability to determine whether such financial assistance from drug companies would apply to a patient’s copay or out-of-pocket maximum. This lack of transparency could lead to patient confusion, unanticipated out-of-pocket costs, and other unnecessary barriers to access that could jeopardize health outcomes if patients decide to forego or discontinue treatment or seek different treatment for non-medical reasons.

“Many Association members describe the difficulty and time-consuming process involved in finding financial assistance for their patients,” said ASCO Chair of the Board Monica M. Bertagnolli, MD, FACS, FASCO. “This additional complexity in coverage policy will only increase the administrative burden on practice staff, who will now need to understand the nuances of co-pay accumulators across different plans and then explain to patients why some of the assistance is not helping them to reach their deductible.”

Furthermore, the proposed rule includes a provision that would alter the automatic re-enrollment process and could cause confusion for individuals purchasing coverage on the ACA Marketplace. Under the proposed rule, individuals currently receiving APTCs equal to or greater than their current premiums—and who therefore pay $0 for insurance coverage—would be automatically re-enrolled in their health plan. However, unless they recertified their financial need during open enrollment, they would not be automatically enrolled in the APTCs. This change could lead to beneficiaries who are eligible for $0 premiums paying higher premiums—or potentially losing coverage altogether.

If a beneficiary misses the open enrollment window in which to reapply for tax credits and is unable to afford coverage without the APTCs, they would remain uncovered for the following year until the next enrollment period. The Association is very concerned that this proposed policy change would lead to gaps in coverage and urges CMS to re-enroll beneficiaries with the APTCs intact.

ASCO will continue share the cancer community’s perspective and work with CMS at every opportunity to improve access to care for people with cancer.

Read the full letter.

Bookmark ASCO in Action for advocacy updates and breaking cancer policy news.