HELP Copays Act
- Sponsor
- Rep. Kean, Thomas H. [R-NJ-7]
- Committees
- Ways and Means Committee (primary)
- Last action
- Dec 4, 2025
Bottom line
The HELP Copays Act aims to lower out-of-pocket costs for patients by requiring insurers to count third-party financial assistance towards deductibles and out-of-pocket maximums, while preserving the tax-advantaged status of HDHPs.
What it actually does
This bill mandates that health insurance plans and issuers must count financial assistance provided by non-profit organizations and prescription drug manufacturers towards an individual's deductible, coinsurance, copayment, and out-of-pocket limits. It amends the Public Health Service Act, the Patient Protection and Affordable Care Act, and the Internal Revenue Code to ensure these third-party payments reduce a patient's direct cost-sharing obligations, particularly for specialty drugs and those subject to utilization management. It also creates a safe harbor to prevent High Deductible Health Plans (HDHPs) from losing their status by complying with this rule for prescription drugs.
Proponents argue
Proponents argue that this bill ensures patients, especially those with chronic conditions relying on expensive specialty medications, directly benefit from financial assistance programs. They contend it prevents 'accumulator adjustment' programs by insurers that effectively negate the value of manufacturer coupons and charity aid, leading to unexpected and burdensome costs for patients. This measure promotes patient access to necessary treatments and improves affordability.
Opponents contend
Opponents, typically health insurers, argue that counting manufacturer coupons towards deductibles can inflate drug prices by removing incentives for patients to choose lower-cost alternatives and for manufacturers to reduce list prices. They contend that accumulator programs are a legitimate tool for managing healthcare costs and promoting value-based care, and that this bill could lead to higher premiums for all enrollees as insurers absorb more costs.
The bill is short and relatively accessible, allowing an informed reader to understand its core provisions and implications within the time given.
Section 2(a)
Application of Financial Assistance Toward Cost-Sharing Requirements (PHSA)
This provision amends the Public Health Service Act to require that health insurance plans and issuers must include amounts paid by, or on behalf of, an individual—including financial assistance from non-profit organizations and prescription drug manufacturers—when calculating a patient's deductible, coinsurance, copayment, and out-of-pocket limit. This means that third-party payments will directly reduce the amount a patient has to pay themselves before their insurance coverage fully kicks in.
Supporters argue
Proponents argue this provision directly addresses a critical barrier to patient access by ensuring that financial aid intended to help patients actually reduces their financial burden, preventing insurers from using 'accumulator adjustment' programs that undermine this assistance.
Critics contend
Opponents contend that this provision could lead to higher premiums for all enrollees by shifting costs to insurers, and may disincentivize drug manufacturers from lowering list prices if their coupons continue to mask the true cost of medications.
Tradeoffs
The provision balances immediate patient affordability against potential long-term impacts on insurance premiums and drug pricing dynamics, creating a tension between direct patient relief and broader healthcare system costs.
Section 2(b)(1)
Conforming Amendment (PPACA Out-of-Pocket Limits)
This section makes a conforming amendment to the Patient Protection and Affordable Care Act (PPACA), clarifying that for the purposes of PPACA's annual out-of-pocket maximums, all forms of cost-sharing (deductibles, coinsurance, copayments, and similar charges) must include amounts paid by or on behalf of an individual, including financial assistance from non-profits and drug manufacturers. This ensures consistency with the main policy change across different federal health laws.
Section 2(b)(3)
HSA Safe Harbor for High Deductible Health Plans (HDHPs)
This provision amends the Internal Revenue Code to create a 'safe harbor' for High Deductible Health Plans (HDHPs). For plan years starting after December 31, 2025, an HDHP will not lose its status (and thus, its enrollees will not lose their eligibility for Health Savings Accounts, or HSAs) simply because it counts third-party financial assistance for outpatient prescription drugs towards the minimum deductible. This is crucial because HDHPs typically cannot cover any costs before the deductible is met, and this safe harbor allows them to comply with the new cost-sharing rules without jeopardizing their tax-advantaged status.
Section 2(c)
Rule of Construction: Scope and Limitations
This section clarifies the scope of the bill's amendments, stating they specifically apply to cost-sharing standards for 'specialty drugs' and drugs 'subject to utilization management.' Crucially, it also explicitly states that the amendments do not impact the use of utilization management tools by insurers, such as prior authorization and step therapy. This limits the application of the new rules to specific high-cost or managed drug categories and assures insurers that their cost-control mechanisms remain intact.
This provision creates a safe harbor for High Deductible Health Plans (HDHPs) by amending the Internal Revenue Code. It ensures that an HDHP will not lose its tax-advantaged status, and its enrollees will not lose their eligibility for Health Savings Accounts (HSAs), if the plan counts third-party financial assistance for outpatient prescription drugs towards the minimum deductible, as required by the main provisions of the bill.
Section 2(b)(3)
Why it matters:This is standard legislative practice for ensuring consistency across different bodies of law (health and tax in this case). It's a technical fix to prevent unintended negative consequences rather than a primary policy statement, making its placement in conforming amendments logical.
Case for: Without this safe harbor, HDHPs that comply with the new cost-sharing rules would inadvertently disqualify their enrollees from using HSAs, undermining a popular tax-advantaged savings mechanism. This provision ensures the bill's primary benefit for patients is not offset by a loss of other important benefits.
Case against: There is no direct case against this specific technical fix, as it prevents an unintended negative consequence. However, critics of the overall bill might argue it adds further complexity to the tax code to accommodate a policy they oppose.
Estimated impact: Prevents millions of HDHP enrollees from losing their HSA eligibility, thereby preserving significant tax benefits and healthcare savings opportunities.