14 Jul Congress Urges CMS to Clarify Co-pay Accumulator Policies

July 14, 2026 ~ Co-pay accumulator programs can increase prescription drug costs for many people, even when they receive financial assistance from drug manufacturers or nonprofit organizations. Congress is now urging the Centers for Medicare and Medicaid Services (CMS) to provide clearer guidance about these programs and how health plans should apply current federal requirements.

In a recent report, the House Appropriations Committee asked CMS to provide clear guidance to health plans and pharmacy benefits managers about complying with requirements related to cost-sharing assistance policies, making special note of co-pay accumulator programs.

While the report does not change the law, it signals that policymakers are paying attention to the impact these programs have on patients and families. Congress wants key stakeholders to improve transparency for consumers on how co-pay accumulators impact prescription drug costs.

What Are Co-pay Accumulators?

Many drug manufacturers and nonprofit organizations offer co-pay assistance programs to help patients cover the out-of-pocket costs for prescription drugs. For example, if a patient’s co-pay is $100, the manufacturer provides a $100 co-pay card, so they would pay $0 when they pick up their prescription at the pharmacy.

A co-pay accumulator is a program used by some health insurance plans that prevents co-pay assistance from counting toward a patient’s deductible or out-of-pocket maximum. As a result, patients may receive temporary help paying for a medication but later face significant costs because those payments did not reduce their deductible or out-of-pocket maximum.

For more detail and examples of how co-pay accumulators work, see our Quick Guide to Co-pay Accumulators and Maximizers, & Alternative Funding Programs.

Why Co-Pay Accumulators Matter for Patients?

When co-pay assistance does not count toward deductibles or out-of-pocket maximums, patients may experience:

• Higher overall out-of-pocket costs.
• Unexpected expenses after assistance funds are exhausted.
• Delays in reaching deductible or out-of-pocket thresholds.
• Potential challenges maintaining access to prescribed treatments.

For patients managing cancer, autoimmune diseases, bleeding disorders, and other serious conditions, these costs may be substantial. Financial barriers can make it harder to start or stay on prescribed treatment.

What Does the Report Say?

The House Appropriations Committee's Fiscal Year 2027 Labor, Health and Human Services, and Education Appropriations report highlights Congress's interest in making sure patient assistance programs work as intended and that patients receive the full benefit of available financial help.

While report language does not change federal law, it can signal priorities for federal agencies and shape future policy discussions.

This language comes amid ongoing national debates about rising health care costs, including whether co-pay assistance should count toward a patient's deductible and out-of-pocket maximum and whether additional federal protections are needed.

Protections Are Expanding, But Not Everyone Is Covered

Currently, federal rules generally allow health plans to use co-pay accumulators, but there are limits in certain situations, such as when a medication does not have a generic equivalent. These rules have changed several times in recent years, which has created a need for clarity on the federal level.

There has also been growing momentum among states to limit the use of co-pay accumulator programs. As of 2026, 28 states have enacted laws that ban or restrict these programs. The most recent state to do so is New Jersey, with its new law already in effect.

However, state-level protections generally apply only to insured health plans regulated by the states, leaving many people with self-insured employer-sponsored plans without similar protections. As a result, many patients may still be affected depending on where they live and the type of health coverage they have.

In this evolving landscape, federal guidance could help bring greater transparency to the use of co-pay accumulators.

How Can You Find Out if Your Plan Uses a Co-Pay Accumulator?

Many people do not realize their plan has a co-pay accumulator until they receive an unexpected bill.

You may want to:

• Review your Summary of Benefits and Coverage or plan documents.
• Look for terms such as “co-pay accumulator adjustment,” “co-pay maximizer,” “coupon adjustment program,” or “co-pay offset program.”
• Contact your insurance company and ask whether co-pay assistance counts toward your deductible and out-of-pocket maximum.

Understanding how your plan treats co-pay assistance can help you anticipate costs and avoid surprises during treatment.

Further Action Needed

For those with high prescription drug costs, co-pay assistance can be a critical lifeline. Congressional attention to co-pay accumulators reflects growing recognition of the financial challenges that patients face when accessing needed medications.

While additional action is needed to create broader protections nationwide, the inclusion of this issue in the House Appropriations Committee report is another step in ensuring that all co-pays count toward patients' financial obligations.

Patients should continue to review their plan documents carefully, ask whether their health coverage uses co-pay accumulator or maximizer programs, and seek assistance if they encounter unexpected cost-sharing requirements.

To support efforts that ensure financial assistance helps patients as intended, check the “Current Issues” sections on our Advocacy page for pending legislation that you can help support.

Learn More

For even more information about this important issue, please refer to our Quick Guide to Co-pay Accumulators and Maximizers, & Alternative Funding Programs.

To better understand all the different costs associated with health insurance, you can:

• Read our Quick Guide to Health Insurance Basics.
• Watch our Animated Video on Health Insurance Basics.
• Listen to the How to Triage Health podcast on Apple Podcasts, Spotify, or our website.

For tips on reducing the impacts of financial toxicity caused by high health care costs, please use the resources on our Navigating Finances page.

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