HELP Copays Act
- Sponsor
- Sen. Marshall, Roger [R-KS]
- Committees
- Health, Education, Labor, and Pensions Committee (primary)
- Last action
- Mar 19, 2026
Bottom line
The HELP Copays Act aims to reduce out-of-pocket costs for patients, especially those with chronic conditions relying on expensive medications, by ensuring third-party financial assistance directly benefits the patient's cost-sharing obligations.
What it actually does
This bill mandates that financial assistance provided by non-profit organizations and prescription drug manufacturers must count towards an individual's health insurance deductible, coinsurance, copayment, and out-of-pocket limits. It amends the Public Health Service Act, the Affordable Care Act, and the Internal Revenue Code to ensure this rule applies broadly, including for High Deductible Health Plans (HDHPs) and specialty drugs, while explicitly preserving insurers' ability to use utilization management tools.
Proponents argue
Supporters argue that this legislation is crucial for patient affordability, preventing health insurers from using 'accumulator adjustment programs' that effectively deny patients the benefit of financial assistance from drug manufacturers or charities. They contend that ensuring this assistance counts towards deductibles and out-of-pocket maximums will make life-saving medications more accessible and affordable for individuals with chronic or rare diseases, who often face exorbitant costs.
Opponents contend
Critics, primarily health insurers, may argue that mandating the inclusion of manufacturer assistance in cost-sharing calculations could lead to higher premiums for all enrollees, as insurers would absorb more costs. They might also contend that such policies could reduce manufacturers' incentives to lower drug prices, as the burden on patients is mitigated by assistance rather than price reductions, potentially contributing to overall healthcare cost inflation.
The bill is concise and clearly written, making it accessible for a quick and informed evaluation by any interested reader.
Section 2(a)
Application of Financial Assistance Toward Cost-Sharing Requirements
This provision amends the Public Health Service Act to require that amounts paid by, or on behalf of, an individual enrolled in a health plan, including financial assistance from non-profit organizations and prescription drug manufacturers, must be counted toward their deductible, coinsurance, copayment, or out-of-pocket limit. This directly addresses practices where such assistance is currently not counted by some insurers.
Supporters argue
Supporters argue this provision ensures that financial assistance genuinely helps patients by reducing their personal financial burden, rather than solely benefiting insurers by allowing them to collect full deductibles despite third-party payments.
Critics contend
Opponents might argue that this could lead to higher premiums across the board as insurers adjust to cover a greater share of costs, or that it could disincentivize drug manufacturers from lowering list prices.
Tradeoffs
This provision balances immediate patient affordability against potential long-term impacts on insurance premiums and drug pricing dynamics within the healthcare system.
Section 2(b)(3)
Safe Harbor for High Deductible Health Plans (HDHPs)
This amendment to the Internal Revenue Code creates a 'safe harbor' for High Deductible Health Plans (HDHPs). It specifies that for plan years beginning after December 31, 2025, a health plan will not lose its HDHP status (and thus eligibility for Health Savings Accounts, HSAs) simply because it counts financial assistance for outpatient prescription drugs towards the minimum deductible. This ensures HDHPs can comply with the new cost-sharing rule without jeopardizing HSA eligibility.
Section 2(c)
Rule of Construction Regarding Utilization Management
This section clarifies that the amendments made by the bill apply specifically to prescription drugs that are specialty drugs and those subject to utilization management (like prior authorization or step therapy). Crucially, it also states that these amendments do not impact the use of such utilization management tools by health plans. This means insurers can still require prior authorization or step therapy for certain drugs, even while financial assistance must count towards cost-sharing.
This amendment ensures that a health plan will not lose its status as a High Deductible Health Plan (HDHP) for tax purposes (and thus, eligibility for Health Savings Accounts, HSAs) if it counts financial assistance for outpatient prescription drugs towards the deductible, effective for plan years beginning after December 31, 2025.
Section 2(b)(3) - Internal Revenue Code of 1986 safe harbor for certain amounts applied to deductibles.
Why it matters:This is standard legislative practice for ensuring consistency across different federal statutes when a new health policy is introduced. It prevents unintended negative consequences for existing tax-advantaged health plans.
Case for: This provision is essential for the bill's effectiveness, as without it, many HDHPs would be unable to comply with the new cost-sharing rules without jeopardizing their tax-preferred status, thereby limiting the bill's reach.
Case against: No significant case against this specific technical amendment, as it resolves a potential conflict in law.
Estimated impact: Ensures continued access to HSA-eligible HDHPs for millions of Americans while allowing them to benefit from financial assistance for prescription drugs.
This section clarifies that the bill's amendments apply to specialty drugs and drugs subject to utilization management, but explicitly states they do not impact the use of utilization management tools (like prior authorization and step therapy) by health plans.
Section 2(c) - Rule of Construction.
Why it matters:This is a common legislative technique to provide clarity and prevent misinterpretation of the bill's scope, addressing potential concerns from stakeholders (insurers) about unintended consequences.
Case for: This clarification is important for ensuring the bill's focus remains on cost-sharing without disrupting insurers' ability to manage drug utilization and costs, which could otherwise lead to opposition from health plans.
Case against: Some patient advocates might argue that preserving utilization management tools could still create barriers to accessing necessary medications, even with reduced financial burden.
Estimated impact: Maintains the status quo for how insurers manage drug access, while changing how patient financial assistance is applied to costs.