Copay battle pits health insurance providers vs third parties, patients caught in the middle

Ohio Statehouse News

COLUMBUS, Ohio (WDTN) – Some health insurance plans are forcing patients to pay their full deductible even if they are getting help from a third party assisting with co-payments. 

This trend has been gaining momentum for the past 18 months, and it is hitting families with patients who have high cost medications the hardest, according to State Representatives Thomas West and Scott Lipps.

Some of these medications are vital for the patient’s survival and often have no generic substitute.

In many cases major pharmaceutical companies are providing this third-party assistance paying the co-pay for the patient. However some health insurance plans are coming back to the patient after the fact and telling him that copayment does not count towards their deductible leaving them in a very difficult financial position, according to lawmakers.

Medical Mutual of Ohio released this statement today when questioned about its participation in such activities:

“Medical Mutual does not prohibit the use of manufacturer co-pay coupons or cards, but the value of these manufacturer co-pay coupons or cards is not applied to a member’s deductible.”

Amber Igielinski is the mother of 10-year-old twin boys living with mild Hemophilia A. This condition results in a reduced ability for the blood to clot and poses a significant risk of death if an injury goes untreated.

Because the disorder is recessive, it can occur in any child without recent family history; as was the case for the Igielinski’s. For the boys, it was discovered shortly after birth when they were circumcised and could not stop bleeding for 8 hours.

“The scariest part was probably the first week of going, ‘okay what do they have? What condition is this? Is it treatable? Is it curable?’ And then the more you learn about it, you wonder well can they recover from this? Is this something they will outgrow? And it’s not,” said Amber.

A single nose bleed nearly killed one of the boys when they were 3 years old, according to Amber.

“We thought it stopped,” said Amber “The blood was draining down his throat. He ended up having to go to the hospital.”

Because of their chronic condition, the boys have a very expensive medication they take that allows them to participate in everyday activities.

“It’s thousands of dollars per unit and it’s one of those things you keep extra on hand because you always want to make sure you have enough,” said Amber.

Some third-parties take care of the co-pay portion of medications for families like the Igielinski’s. However, some health insurance companies have begun either rejecting those payments or not allowing them to apply to a patient’s deductible.

Amber says her insurance company has told her to prepare for possible changes to her plan.

“We were told that, ‘We’re trying to do away with it. You still have it right now, but we’re trying to get rid of it’,” said Amber. “They didn’t really say why; it was just, ‘We don’t believe in it. You guys should be paying your fair share’.”

Lawmakers at the Statehouse say that isn’t right. State Representatives Scott Lipps and Thomas West have worked together across the aisle on other legislation that addresses with medication costs.

When they found out the health insurance companies were doing this, they were immediately concerned for families like the Igielinski’s and for others who find themselves in different circumstances.

“They may not be able to afford it, think of that; they can’t afford it, someone’s helping them with it and the insurance company says ‘no;’ the patient goes without the medication,” said Lipps.

Lipps and West have had long conversations with another lawmaker who knows the importance of having medication on hand to address a Hemophilia condition. Freshman lawmaker, State Representative Randi Clites’ son has the disorder as well.

“It made it real for us because it showed us the dramatic impact that when January 1st hit, and their new deductible started; it showed us the financial turmoil it puts a family in,” said Lipps.

NBC 4 reached out to several health insurance companies serving Ohioans. Our calls were only returned by Medical Mutual of Ohio.

What remains unclear is why the insurers are taking this stance.

From the lawmaker’s perspective, and the patient’s, what does it matter where the money comes from as long as the bill is paid?

“We feel like the [assistance] helps us have a good life, and from the insurance company if they get [the payment] I don’t understand why it matters to them,” said Amber.

Clite says she hopes this is just a misguided attempt by health insurers to reduce health costs and nothing more. And even if it is, Lipps and West plan to see an end put to the practice like they did with PBM Gag Orders.

“Let’s try to resolve this before we even have to do legislation,” said West. “But if we have to bring legislation, we’re gonna bring it.”

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