HR 6423
HELP Copays Act
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Bill overview
The Help Ensure Lower Patient Copays Act amends existing healthcare laws to broaden the definition of what counts toward a patient’s deductible, coinsurance, or copayment. Specifically, it includes financial assistance provided by non-profit organizations and prescription drug manufacturers when calculating these costs. The bill also makes changes to how the Affordable Care Act and the Public Health Service Act define these terms, and establishes a safe harbor for plans that include such assistance in their calculations.
Key provisions
- Expands the definition of cost-sharing to include financial assistance from non-profit organizations and prescription drug manufacturers.
- Modifies the Patient Protection and Affordable Care Act to incorporate this expanded definition.
- Updates the Public Health Service Act to align with the changes in the Affordable Care Act.
- Creates a safe harbor for plans that include prescription drug assistance in their deductible calculations starting in 2026.
- Applies the changes to specialty drugs and drugs subject to utilization management.
Who is affected
- Individuals enrolled in health insurance plans (group and individual)
- Health insurance issuers
- Non-profit organizations
- Prescription drug manufacturers
- Healthcare providers
Notable changes
- The bill expands the calculation of deductibles, coinsurance, and copayments to include financial assistance.
Sponsors
Official sponsors from legislative records.
Primary sponsor
Thomas H. Kean
Cosponsors
Becca [D-VT-At Large] Balint
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119th CONGRESS — 1st Session
H. R. 6423
IN THE HOUSE OF REPRESENTATIVES
A BILL
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.
This Act may be cited as the Help Ensure Lower Patient Copays Act HELP Copays Act
or the
.
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:
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.