March 5, 2025
Mr. Marshall (for himself, Mr. Kaine, Mr. Tillis, Mr. Markey, Ms. Murkowski, and Mr. Merkley) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions
To amend title XXVII of the Public Health Service Act to apply financial assistance towards the cost-sharing requirements of health insurance plans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
Section 1. Short title
This Act may be cited as the Help Ensure Lower Patient Copays Act
or the HELP Copays Act
.
Sec. 2. Application of financial assistance toward cost-sharing requirements
(a) Application 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.
.
(b) Conforming amendments
(1) PPACA
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:
(C) Application of terms
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.
(2) PHSA
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
.
(3) Internal Revenue Code of 1986 safe harbor for certain amounts applied to deductibles
Section 223(c)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following new subparagraph:
(H) Safe harbor for certain amounts applied to deductibles
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.
(c) Rule of construction
The amendments made by this section shall —
(1)
apply to standards relating to deductibles, coinsurance, copayments, or limits with respect to prescription drugs that are specialty drugs;
(2)
apply to standards relating to deductibles, coinsurance, copayments, or limits with respect to drugs that are subject to utilization management; and
(3)
not impact the use of utilization management tools, including prior authorization and step therapy.
(d) Effective date
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.