Twenty-six states, the District of Columbia, and Puerto Rico now have laws making it illegal for health insurers to pocket drug-manufacturer copay assistance without crediting it to a patient’s deductible. The practice is called a copay accumulator, and it quietly costs chronic-illness patients thousands of dollars a year. Last year, eleven states with laws on the books still had insurers running accumulators. This year, six of those eleven cleaned up entirely. Zero violations. The law worked. But four new states passed laws in 2025, and the same insurers are already running accumulators in those four states for the 2026 plan year. The cycle repeats.

The story so far

In 2019, HHS restricted copay accumulators to brand drugs with a generic alternative, then reversed itself a year later. Patient groups sued, and in September 2023 a federal judge vacated the reversal, snapping the original restriction back into effect. HHS has not enforced it since, and neither the 2026 nor 2027 payment rules touched the issue. The federal floor exists on paper; in practice, it offers patients nothing.

State legislatures filled the vacuum. By the 2026 plan year, 26 states plus DC and Puerto Rico had laws on the books. Avalere puts the affected population at 26 million Americans, about 19% of the U.S. commercial market. Bipartisan support, in red and blue states alike. The list keeps growing. North Dakota, Indiana, Maryland, and Iowa all passed laws in 2025. New Jersey signed on January 9, 2026.

What the laws actually say

Roughly half the state statutes are broadly written. Connecticut, Delaware, Illinois, Iowa, Louisiana, New Jersey, New Mexico, New York, Oklahoma, Virginia, West Virginia, and Puerto Rico use a variant of the same sentence: the insurer shall include any amount paid by the enrollee or on behalf of the enrollee by another person. No exception. No carve-out.

The other half (Arizona, Arkansas, Colorado, DC, Georgia, Indiana, Kentucky, Maine, Maryland, North Carolina, North Dakota, Oregon, Tennessee, Texas, Vermont, Washington) track the federal rule and carve out brand drugs that have a medically appropriate generic equivalent. The carve-out is narrow. The big specialty drugs (Humira, Biktarvy, Stelara, Ocrevus) almost never have generics.

Oklahoma is worth a sentence on its own. The state codified the violation as an “unfair claim settlement practice” under 36 O.S. § 1250.5(18), which puts compliance under an existing civil-penalty regime. As far as the public record shows, the Oklahoma Insurance Department has never enforced it. Oklahoma still got to zero copay accumulators for the 2026 plan year anyway.

The compliance gap

The most thorough public dataset on who is complying comes from The AIDS Institute, an HIV/HCV patient-advocacy organization that has reviewed marketplace plan documents in all 50 states annually since 2020. (Worth disclosing: the Institute’s reports are funded in part by drugmakers, including Genentech, Johnson & Johnson, AbbVie, and Pfizer. Those drug companies’ copay-assistance programs are the money being pocketed.) The methodology is replicable. Pull each state’s marketplace plan filings, search the policy language for accumulator clauses, call customer service when the documents are unclear.

Chart 1. Six states cleaned up. Four new states are already violating.
Who moved — and who didn’t — for the 2026 plan year
Six states that were on last year’s violator list now show zero plans running accumulators. Four states that passed laws in 2025 already have violations in their first plan year under statute.
CLEANED UP FOR 2026 Was on 2025 violator list → zero violations in 2026 Colorado ✓ Zero violations Georgia ✓ Zero violations Illinois ✓ Zero violations Oklahoma ✓ Zero violations Oregon ✓ Zero violations Texas ✓ Zero violations NEW LAW, ALREADY VIOLATING Law passed 2025 → plan documents already out of compliance Indiana Anthem Iowa UnitedHealthcare, Medica Maryland Wellpoint (Elevance) North Dakota Medica
Named-violator findings are based on marketplace plan document review. Several state insurance departments, when contacted by The AIDS Institute after last year’s report, said they do not believe the named insurers are implementing the practices their plan documents describe. Findings should be independently verified against current 2026 plan filings.
Source: The AIDS Institute, “Shortchanged: The Patient Impact of Copay Accumulator Policies in 2026” (February 2026).

Six states from last year’s eleven-state violator list now show zero plans with copay accumulators. Colorado, Georgia, Illinois, Oklahoma, Oregon, and Texas. That is the good news. The bad news is that nine states still have at least one major insurer running accumulators in their plan documents, and four of those nine (Indiana, Iowa, Maryland, North Dakota) only passed their laws in 2025. Their plan documents for 2026 are already out of compliance.

The names on the violator list are remarkably consistent. UnitedHealthcare appears as a named violator in six of the nine states with copay accumulators in violation of state law: Indiana, Iowa, Louisiana, North Carolina, Tennessee, and Washington. Last year UHC was named in six different states (Georgia, Louisiana, North Carolina, Oklahoma, Tennessee, Washington). The overlap is half. The states UHC complies in are the states UHC had to comply in for a previous plan year. New state laws get new UHC violations.

The names don’t change. The states change.

Medica appears in Iowa and North Dakota, both new-law states. BlueCross BlueShield of Tennessee, the dominant carrier in its state, is still on the list. AmeriHealth Caritas Next cleaned up in North Carolina but is still flagged in Delaware. Wellpoint (Elevance Health) shows up in Maryland. Anthem in Indiana. These are not regional outliers. They are the largest publicly traded health insurers in the country.

The AIDS Institute reports a new wrinkle in this year’s findings. After last year’s report, the organization brought its findings to several state insurance departments. The departments came back with a consistent response: after talking to the insurers, they no longer believe the carriers are actually implementing the policies their plan documents describe. So the contract language says one thing, the carriers tell the regulators they are doing the opposite, and the patient has no way of knowing which is true until they get charged at the pharmacy counter.

What it costs the patient

The AIDS Institute uses a worked example. A patient on a $1,680-a-month specialty drug has a $4,600 deductible, an $8,550 out-of-pocket maximum, and $7,200 in manufacturer copay assistance. Without an accumulator, the patient hits the out-of-pocket cap in August. They pay $1,350 out of pocket. The insurer collects $8,550. With an accumulator, the same patient pays $7,960 out of pocket, nearly six times more, and the insurer collects $15,160.

Chart 2. Patient out-of-pocket cost over twelve months
With vs. without a copay accumulator
Same drug, same plan, same copay assistance. The only variable is whether the insurer counts manufacturer copay assistance toward the deductible. Without an accumulator the patient hits their OOP max in August and owes nothing more. With an accumulator, manufacturer copay assistance is invisible to the deductible and the patient pays nearly six times as much for the year.
Without accumulator (patient pays $1,350) With accumulator (patient pays $7,960)
$9,000 $7,000 $5,000 $3,000 $1,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cumulative patient OOP cost $1,350 OOP cap hit in August $7,960
Illustrative example from The AIDS Institute using a $1,680/month specialty drug, $4,600 deductible, $8,550 out-of-pocket maximum, and $7,200 in annual manufacturer copay assistance ($600/month). Without an accumulator, the copay assistance counts toward the deductible; the patient hits the OOP cap in August and pays $1,350 total. With an accumulator, the manufacturer assistance is pocketed by the insurer and does not count; the patient owes $7,960 and the insurer collects $15,160.
Source: The AIDS Institute, “Shortchanged: The Patient Impact of Copay Accumulator Policies in 2026” (February 2026).

Many patients cannot pay. IQVIA prescription-claims data shows that when out-of-pocket costs at the pharmacy counter hit $250, more than 70% of patients walk away without their medication. Under ACA Section 1302(c)(1), HHS sets a federal ceiling on out-of-pocket costs that every non-grandfathered health plan must stay beneath; for 2026, that ceiling is $10,600 for self-only coverage and $21,200 for a family. Both are records, both growing faster than wages, and both fall on patients who already lost their enhanced ACA premium tax credits at the end of 2025.

What’s missing, and what’s coming

Even if every state’s law worked perfectly, two structural problems would remain.

The first is ERISA preemption. State insurance laws don’t reach self-funded employer health plans, which cover most of the U.S. commercial market. Iowa’s 2024 attempt to apply its copay-counts law to self-funded plans is likely headed for federal preemption litigation.

The second is the maximizer escalation. PBMs that can’t run accumulators are partnering with outside vendors instead. SaveOnSP works with Express Scripts. PrudentRx works with CVS Caremark. The vendors reclassify specialty drugs as “non-essential health benefits” and capture the full annual value of manufacturer copay assistance through a different mechanism. The AIDS Institute documents at least one plan running a variable-copay program in twelve states.

The federal HELP Copays Act would extend the count-the-copay rule to ERISA plans. Senators Roger Marshall and Tim Kaine reintroduced it in the Senate on March 7, 2025. Representative Tom Kean and a bipartisan group reintroduced it in the House on December 4, 2025. Both bills are sitting in committee.

The bottom line State laws against copay accumulators work, eventually. Six states forced their insurers into compliance over the past plan year. The next four states are just starting that fight. The same carriers are running the same playbook in each new statute that hits the books, and there is nothing in the structure of how the laws are enforced today that breaks the cycle. UnitedHealthcare alone is on six violator lists this year. Compliance happens one state at a time, on the insurer’s clock, with the patients picking up the bill in between.
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Issue No. 2 of The Olsen Tribune. Written from a close reading of The AIDS Institute’s “Shortchanged: The Patient Impact of Copay Accumulator Policies in 2026” (February 2026), the operative state statutes reproduced in that report’s Appendix 4, the September 2023 ruling in HIV+Hepatitis Policy Institute v. HHS, Avalere’s commercial-lives analysis, the bill texts of S.864 and H.R. 6423 in the 119th Congress, and HHS, Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability, 90 Fed. Reg. 27074 (June 25, 2025) (source for 2026 out-of-pocket maximum limits). The Institute reports that several state insurance departments, when contacted, said they do not believe the named insurers are implementing the practices their plan documents describe; named-violator findings should be independently verified against current 2026 plan documents before further reporting. Charts are illustrative; underlying data is sourced inline. Not investment advice.