If you rely on a manufacturer coupon card to help pay for an expensive specialty medication, your insurance plan may be taking that money and not counting it toward your deductible, forcing you to pay out of pocket as if the coupon never existed.
That is the finding of a new investigation by KFF Health News published July 7, 2026. The investigation found that for 2026, nearly 40% of ACA marketplace plans use what the insurance industry calls "copay accumulator programs" — arrangements that intercept drug manufacturer coupon cards, collect the funds, and refuse to count them toward the patient's annual deductible or out-of-pocket maximum.
The result: patients who believe their drug company assistance is working can suddenly face unexpected and enormous bills once the coupon is exhausted — at the moment they are least prepared for it.
Why This Matters
Specialty medications for conditions including autoimmune diseases, multiple sclerosis, diabetes, HIV, and cancer can cost thousands to tens of thousands of dollars per month. Drug manufacturers frequently offer coupon cards — sometimes called "copay assistance," "patient support cards," or "manufacturer coupons" — to help patients afford these drugs. For years, most patients assumed those cards reduced their drug costs and counted toward their insurance plan's annual out-of-pocket maximum.
Copay accumulator programs change that assumption without making it obvious. Under these programs, the coupon is used at the pharmacy — reducing the patient's immediate payment — but the insurance company records the transaction as if the patient paid nothing out of pocket. When the coupon's value runs out, the patient is suddenly responsible for their deductible and cost-sharing as if the year had just begun, with no warning and no runway to budget for it.
The practice is currently prohibited in Medicare and Medicaid under federal anti-kickback statutes. But for the tens of millions of Americans enrolled in individual and commercial health insurance plans, the practice is permitted unless the state where they live has specifically banned it.
What We Know So Far
According to KFF Health News, which cited a 2026 review by The AIDS Institute — a nonprofit organization that has actively opposed copay accumulator programs — nearly 40% of ACA marketplace plans for 2026 use such a program. In Florida alone, 10 of the 16 insurers selling plans on the ACA marketplace use copay accumulators.
The investigation profiles Larry Gruber, a fitness coach from Wilton Manors, Florida, who has relied on a coupon card from Amgen, the manufacturer of his psoriatic arthritis medication Enbrel, for 16 years. Enbrel costs more than $7,700 per month — a price Gruber cannot reduce because no medically equivalent generic exists for the drug. In prior years, when he held coverage in Illinois and Louisiana — states that prohibit copay accumulators — the coupon counted toward his deductible and he usually hit his out-of-pocket maximum by February. His drug cost fell to $0 for the rest of the year.
This year, after moving to Florida and enrolling in Oscar HMO of Florida, he encountered a copay accumulator for the first time. Oscar kept the value of Amgen's coupon and required Gruber to meet the plan's $10,600 out-of-pocket maximum entirely on his own. Had the coupon counted as it did in his previous plans, he would have owed roughly $3,000 in covered services.
Matt Choffin, Florida market president for Oscar Health, told KFF Health News that the company uses copay accumulators to manage rising prescription costs and "to keep monthly premiums as low as possible." His comments did not address Gruber's specific case.
Where the Risk Is Highest
Patients most at risk are those who:
- Take brand-name specialty medications for chronic conditions and rely on manufacturer coupon assistance
- Live in states that have not enacted laws prohibiting copay accumulators
- Hold individual ACA marketplace plans or commercial group plans rather than Medicare or Medicaid
According to The AIDS Institute's 2026 report, states that have laws restricting copay accumulators as of 2026 include Iowa, Louisiana, New Jersey, New Mexico, New York, Oklahoma, Virginia, West Virginia, and Puerto Rico. States with partial restrictions include Maine, Maryland, North Carolina, North Dakota, Oregon, Tennessee, Texas, Washington, and Vermont. Most remaining states — including Florida, Georgia, Pennsylvania, Michigan, Ohio, and Illinois (for commercial plans, though marketplace plans may vary) — have limited or no such protections.
Patients in states without protections who enroll in ACA marketplace plans should actively inquire about their plan's copay accumulator status before assuming their manufacturer assistance will count.
What Experts and Advocates Say
"The real insult here is that they're taking the money that's intended to help you," Gruber told KFF Health News. "I feel desperate, pressed against the wall, and squeezed."
Sean Dickson, a senior vice president for AHIP, the trade association representing health insurers, told KFF Health News that drugmakers offer "short-term 'discounts' to justify overcharging Americans in the long term, driving up healthcare costs for everyone." He added that research shows limiting copay coupons can reduce premiums and lower consumer out-of-pocket costs.
Sarah Ryan, a spokesperson for the Pharmaceutical Research and Manufacturers of America, countered that copay assistance helps patients access medications at reduced or no cost, and that insurer practices that intercept that assistance shift costs back to patients who often have no lower-cost alternative.
Patient advocates argue that both positions miss a critical distinction: for patients on brand-name medications with no generic equivalent, copay accumulators do not encourage smarter drug choices. They simply require the patient to pay more money out of pocket for the same drug they would have taken anyway.
What the Evidence Shows — and What It Does Not
Copay accumulator programs are a legal and disclosed insurance practice. The disclosure is typically buried deep in policy documents — Gruber's evidence of coverage contained the relevant disclosure on page 127 of a 168-page document. Whether such disclosure constitutes meaningful informed consent for the average consumer selecting a health plan during open enrollment is a question that patient advocates and some state regulators have raised, but that federal law has not yet resolved.
The Biden administration attempted to restrict copay accumulators through federal regulation in 2021 but faced legal challenges. As of 2026, a final federal rule addressing the practice has not been issued, leaving regulation primarily at the state level.
Whether copay accumulators meaningfully lower premiums across the insured population — as insurers claim — or simply shift costs from insurers to patients without corresponding premium savings has not been resolved by independent research in a way that all stakeholders accept.
MedicalDaily Consumer Alert Check
- Practice: Copay accumulator programs in ACA marketplace and commercial insurance plans
- Scope: ~40% of ACA marketplace plans in 2026, per The AIDS Institute review
- Who is affected: Patients with chronic conditions using brand-name specialty drugs with manufacturer coupon assistance
- What it does: Insurers accept coupon payments but do not count them toward the patient's deductible or out-of-pocket maximum
- Prohibited in: Medicare, Medicaid, and HSA-linked high-deductible plans
- State bans: Approximately 9 states plus Puerto Rico have enacted restrictions
- Federal regulation: No final federal rule currently in force
- What readers should know: Check your plan's documents and call your insurer before assuming your coupon card counts toward your deductible
Who Is Most Affected?
The patients at greatest financial risk are those who:
- Take specialty biologics or brand-name drugs for autoimmune diseases (rheumatoid arthritis, psoriatic arthritis, Crohn's disease, lupus), multiple sclerosis, HIV, cancer, or diabetes
- Rely on manufacturer coupon assistance to meet their annual out-of-pocket maximum
- Switched insurance plans, moved to a new state, or changed employers since last year
- Live in states without copay accumulator protections
- Have insurance through an ACA marketplace or commercial group plan
Patients on Medicare, Medicaid, or HSA-paired high-deductible plans are protected from copay accumulators by federal law.
What You Can Do Now
- Call your insurance company directly and ask whether your plan uses a copay accumulator program. Specifically ask: "Does my plan use a copay accumulator or copay maximizer for specialty drugs?" Get the answer in writing.
- Read your evidence of coverage document. The disclosure, if your plan has a copay accumulator, is typically in the benefit terms section. Search for phrases like "third-party assistance," "manufacturer assistance," or "out-of-pocket maximum" limitations.
- Contact your state's insurance regulator to ask whether your state restricts copay accumulators. Your state's insurance department website will have guidance on patient protections.
- During open enrollment, compare plans on more than premium and deductible. If you use specialty drugs, ask each plan specifically whether manufacturer coupons count toward your out-of-pocket maximum before enrolling.
- Contact your drug's manufacturer. Amgen, AbbVie, Bristol Myers Squibb, Sanofi, and other specialty drug companies typically have patient advocacy teams that can advise on navigating copay accumulator plans.
- Talk to a patient advocate. Organizations like the Patient Advocate Foundation and the Patient Access Network Foundation may be able to help bridge financial gaps for patients in states without copay accumulator protections.
Cost and Access: What Patients Should Know
If your plan uses a copay accumulator and your drug coupon does not count toward your deductible, you face the full cost-sharing burden your plan requires — which on many ACA marketplace plans in 2026 can exceed $9,000 annually after the KFF reported average deductible rose to $3,786 for 2026, one of the largest single-year increases on record.
For patients who cannot afford the out-of-pocket burden without coupon assistance counting:
- Patient assistance programs (PAPs) : Most major specialty drug manufacturers offer free or deeply discounted medication for patients who cannot afford cost-sharing. Ask your prescribing physician or call the manufacturer directly.
- Nonprofit bridges : The Patient Access Network Foundation and HealthWell Foundation provide co-pay assistance grants for patients with specific diseases who are underinsured.
- State pharmaceutical assistance programs : Several states run additional assistance programs for residents whose specialty drug costs are not covered. Ask your state insurance regulator or NeedyMeds for state-specific programs.
- Switching plans during special enrollment : If your plan's copay accumulator was not clearly disclosed when you enrolled and you can demonstrate it, some states allow a special enrollment window. Contact your state's insurance consumer advocate.
What Happens Next
Federal regulation of copay accumulators has stalled for several years. The current administration has not issued a final rule. Consumer advocates and some congressional members have called for explicit federal prohibition of copay accumulators in ACA marketplace plans — aligning them with the Medicare and Medicaid standard — but no legislation has passed.
At the state level, legislative advocacy is ongoing. The AIDS Institute and other patient organizations continue to push for state bans in the remaining unprotected states. Patients in those states can contact their state legislators to support copay accumulator prohibition bills.
MedicalDaily will monitor federal rulemaking and state legislative activity on copay accumulators and update this story as developments warrant.
The Bottom Line
Nearly 40% of ACA marketplace plans in 2026 use copay accumulator programs that take drug company assistance meant for patients and do not count it toward the patient's deductible or out-of-pocket maximum. The practice is legal in most states, disclosed in lengthy insurance documents most patients never read, and currently unregulated at the federal level. If you rely on a manufacturer coupon card to afford a specialty medication, call your insurer today and ask directly whether your plan uses a copay accumulator. The answer could change your financial planning for the rest of the year.
