Using the existing mandated 5010 270/271 response, how would payers report information on Accumulator and Maximizer programs?
Payers are starting to implement programs called copay maximizers and copay accumulators as a way to control costs on expensive specialty pharmacy products where certain out of pocket dollars are excluded from counting toward a commercially insured patient’s deductible and maximum out-of-pocket limit as they otherwise would have.
Within the 271, there is no way, using 005010X279A1, to accommodate a codifiable way to return this information restricting the accumulators from being satisfied by financial assistance programs, such as copay accumulator adjustment program (CAAP), or addressing details related to copay maximizer programs.
Related RFIs: 1691, 848, 1566, 881
While there is no requirement to return these types of financial limitations, we suggest the language in the EB and MSG segments below to help standardize the response using the MSG segment.
If the payer has a way to determine that a pharmaceutical company has an assistance program at the time the 270 is processed, it is recommended the 271 return one of the following, depending on the payer’s system capabilities:
EB01=CB (COVERAGE BASIS) OR D (BENEFIT DESCRIPTION)
MSG*COPAY ASSISTANCE WILL APPLY TO THE REMAINING BALANCE OF THE MEMBER’S OUT OF POCKET OR DEDUCTIBLE ACCUMULATORS
EB01=CB (COVERAGE BASIS) OR D (BENEFIT DESCRIPTION)
MSG*COPAY ASSISTANCE WILL NOT APPLY TO THE REMAINING BALANCE OF THE MEMBER’S OUT OF POCKET OR DEDUCTIBLE ACCUMULATORS
If this is functionality that is needed for your business and not currently supported in a published TR3, please submit an X12 maintenance request at https://x12.org/resources/forms/maintenance-requests