The HELP Copays Act (S. 864) would modify federal health law to ensure that financial assistance—such as payments from individuals, non-profit organizations, and prescription drug manufacturers—counts toward patients’ cost-sharing for health plans. Specifically, it requires standards defining deductibles, coinsurance, copayments, and out-of-pocket limits to include these external payments and to count them toward the applicable limit. The bill also makes conforming amendments to the Affordable Care Act, the Public Health Service Act, and the Internal Revenue Code to ensure these payments are treated as reducing patients’ out-of-pocket costs for deductibles, co-insurance, co-pays, and drug expenses. The changes would apply to plan years beginning on or after January 1, 2026. The bill clarifies that these changes apply to certain prescription drugs, to drugs subject to utilization management, and that existing utilization-management tools (like prior authorization and step therapy) are not to be impacted.
Key Points
- 1Converts external financial assistance into countable components of cost-sharing: deductibles, coinsurance, copayments, and out-of-pocket limits.
- 2Applies to payments made by individuals, as well as assistance from non-profits and prescription drug manufacturers.
- 3Requires parallel amendments to the ACA and PHSA to ensure deductibles and related limits reflect these external payments, including for prescription drugs.
- 4Adds a safe harbor in the Internal Revenue Code to allow counting payments toward deductibles for HDHP determinations (post-2025 plan years).
- 5Effective for group health plans and health insurance issuers for plan years beginning on or after January 1, 2026; preserves use of utilization-management tools (prior authorization, step therapy) but limits broader impacts.