Sponsor
Jake Auchincloss
Representative · D-MA
Representative · D-MA
The bill reduces out-of-pocket prescription spending for many enrollees by capping annual drug costs starting in 2027, but it may raise premiums and prompt insurer cost-control measures that could limit access and will require clarifying implementation guidance.
Many enrollees in marketplace and large-group plans subject to essential health benefits will get predictable maximum prescription drug costs starting in 2027 because annual drug cost-sharing will be capped for those plans.
People with self-only and family coverage will have annual prescription drug cost-sharing caps (self-only capped at $2,000 in 2027; families/non–self-only capped at twice the self-only amount), reducing out-of-pocket spending and limiting catastrophic drug bills for households.
The annual cap will be indexed after 2027 by the premium adjustment percentage, helping keep the cap's protection against inflation over time.
Insurers may respond by narrowing drug formularies, increasing prior authorization, or narrowing provider networks to control costs, which could restrict access or continuity of specific medicines for patients.
Taxpayers, middle-class families, and employers could face higher premiums if insurers raise premiums to offset reduced cost‑sharing revenue from drug users.
Unclear or incomplete conforming amendments in the statutory text could create implementation confusion for plans and regulators, complicating state and local administration until clarifications are issued.
Based on analysis of 2 sections of legislative text.
Imposes an annual cap on prescription drug cost-sharing for ACA essential health benefit plans: $2,000 self-only in 2027 (family = twice) and indexed thereafter.
Official title: To amend the Patient Protection and Affordable Care Act to establish an out-of-pocket limit on spending for prescription drugs.
Introduced November 20, 2025 by Jake Auchincloss · Last progress November 20, 2025
Establishes an annual dollar cap on out-of-pocket prescription drug cost-sharing for health plans subject to the ACA’s essential health benefits. For plan years beginning on or after January 1, 2027, the cap is $2,000 for self-only coverage in 2027 (indexed thereafter by the existing premium adjustment percentage) and twice that amount for other than self-only coverage (family coverage). The cap is added to the ACA’s existing cost-sharing rules and applies to plans that must follow essential health benefit requirements.