S864-119

1. Short title This Act may be cited as the Help Ensure Lower Patient Copays Act or the HELP Copays Act.

2. Application of financial assistance toward cost-sharing requirements Section 2715(g)(1) of the Public Health Service Act (42 U.S.C. 300gg–15(g)(1)) is amended by adding at the end the following: In developing the standards for defining the terms deductible, coinsurance, copayment, and out-of-pocket limit (as described in paragraph (2)), such standards shall provide that such terms include amounts paid by, or on behalf of, an individual enrolled in a group health plan or group or individual health insurance coverage, including financial assistance offered by non-profit organizations and prescription drug manufacturers, and that such amounts shall be counted toward such deductible, coinsurance, copayment, or limit, respectively.. Section 1302(c)(3) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(c)(3)) is amended by adding at the end the following new subparagraph: For purposes of subparagraph (A), the terms deductible, coinsurance, copayment, or similar charge and any other expenditure described in clause (ii) of such subparagraph shall include amounts paid by, or on behalf of, an individual enrolled in a group health plan or group or individual health insurance coverage, including financial assistance offered by non-profit organizations and prescription drug manufacturers, and such amounts shall be counted toward such deductible, co-insurance, co-payment, charge, or other expenditure, respectively. Section 2707(b) of the Public Health Service Act (42 U.S.C. 300gg–6(b)) is amended by adding at the end the following new sentence: For purposes of the previous sentence, such limitation shall be applied to prescription drugs as if the reference to essential health benefits in section 1302(c)(3) of the Patient Protection and Affordable Care Act were a reference to any item or service covered under the plan included within the prescription drug category of essential health benefits as described in (b)(1)(F) of such section.. Section 223(c)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph: In the case of plan years beginning after December 31, 2025, a plan shall not fail to be treated as a high deductible health plan by reason of counting amounts paid by, or on behalf of, an individual, including financial assistance offered by non-profit organizations and prescription drug manufacturers for outpatient prescription drugs, when determining whether the minimum deductible under subparagraph (A) has been satisfied. The amendments made by this section shall — apply to standards relating to deductibles, coinsurance, copayments, or limits with respect to prescription drugs that are specialty drugs; apply to standards relating to deductibles, coinsurance, copayments, or limits with respect to drugs that are subject to utilization management; and not impact the use of utilization management tools, including prior authorization and step therapy. This section, and the amendments made by this section, shall apply to group health plans and health insurance issuers for plan years beginning on or after January 1, 2026. (C)Application of termsFor purposes of subparagraph (A), the terms deductible, coinsurance, copayment, or similar charge and any other expenditure described in clause (ii) of such subparagraph shall include amounts paid by, or on behalf of, an individual enrolled in a group health plan or group or individual health insurance coverage, including financial assistance offered by non-profit organizations and prescription drug manufacturers, and such amounts shall be counted toward such deductible, co-insurance, co-payment, charge, or other expenditure, respectively.. (H)Safe harbor for certain amounts applied to deductiblesIn the case of plan years beginning after December 31, 2025, a plan shall not fail to be treated as a high deductible health plan by reason of counting amounts paid by, or on behalf of, an individual, including financial assistance offered by non-profit organizations and prescription drug manufacturers for outpatient prescription drugs, when determining whether the minimum deductible under subparagraph (A) has been satisfied..