HR6423-119

What This Bill Does

The HELP Copays Act changes how health plans treat third-party assistance for patient cost sharing. It amends the Public Health Service Act summary-of-benefits standards so deductibles, coinsurance, copayments, and out-of-pocket limits include amounts paid by or on behalf of an enrolled individual, including nonprofit financial assistance and prescription drug manufacturer assistance. It makes parallel changes to Affordable Care Act annual cost-sharing limit rules so those assistance amounts count toward deductibles, coinsurance, copayments, similar charges, and other covered expenditures. It also applies the cost-sharing limitation to prescription drugs as if the reference to essential health benefits covered any item or service within the prescription drug category. Finally, it creates a tax-code safe harbor so, for plan years beginning after December 31, 2025, certain amounts applied to deductibles do not cause a high deductible health plan to lose HDHP status.

Who Benefits and How

Patients using manufacturer copay assistance or nonprofit assistance benefit because those payments would count toward deductibles and out-of-pocket limits instead of being excluded by accumulator policies. People with high-cost prescription drugs benefit most directly because assistance can help them reach cost-sharing limits sooner. Nonprofit assistance organizations and drug manufacturers benefit because their assistance more directly reduces patient cost-sharing obligations. Employers and plan sponsors that want HDHP-compatible assistance rules benefit from the tax-code safe harbor.

Who Bears the Burden and How

Group health plans and health insurance issuers must count third-party assistance toward cost-sharing obligations and may face higher plan costs when patients reach deductibles or out-of-pocket maximums sooner. Pharmacy benefit managers and accumulator vendors may need to change benefit designs. Federal health and tax administrators must update standards, cost-sharing rules, and HDHP safe-harbor guidance. Premiums could rise if plans absorb more prescription drug cost sharing.

Key Provisions

• Amends Public Health Service Act standards so deductibles, coinsurance, copayments, and out-of-pocket limits include third-party assistance.
• Amends ACA cost-sharing limit rules to count nonprofit and manufacturer financial assistance toward patient obligations.
• Applies annual cost-sharing limits to covered prescription drugs in the prescription drug essential health benefit category.
• Creates an HDHP safe harbor for certain assistance applied to deductibles after December 31, 2025.