Sponsors (52)
The bill makes third-party patient assistance count toward deductibles and out-of-pocket limits (and preserves HSA eligibility for HDHP enrollees), increasing affordability for many patients — especially those on specialty or chronic-care drugs — while raising the risk of higher plan costs, manufacturer program changes, and short-term consumer confusion during implementation.
Patients with employer or individual health plans — especially people with chronic conditions and those using specialty drugs — will have manufacturer or nonprofit third-party assistance counted toward their deductibles and out-of-pocket limits, reducing their direct out-of-pocket spending beginning in plan years after 12/31/2025.
Enrollees in high-deductible health plans (HDHPs) can use manufacturer/nonprofit assistance for outpatient drugs without losing HSA eligibility because the bill creates an IRS safe-harbor for plan years after 12/31/2025.
The rule explicitly covers specialty drugs and drugs subject to utilization management, so patients who face high cost-sharing due to specialty status or utilization controls can benefit from assistance counting toward cost-sharing limits.
Health plans and issuers will likely face higher paid claims and added administrative complexity to track and aggregate third-party assistance, which could lead to higher premiums or administrative costs passed on to employers and consumers.
Drug manufacturers may change or restrict copay/assistance program designs (for example tightening eligibility) to limit their exposure, which could reduce assistance availability for some patients, particularly lower-income or marginally eligible individuals.
Enrollees may be confused about which third-party payments count and how they apply to deductibles and out-of-pocket limits during the transition to the new rule (effective for plan years after 12/31/2025), creating short-term uncertainty and potential billing/enrollment issues.
Based on analysis of 2 sections of legislative text.
Requires health plans to count manufacturer and nonprofit patient-assistance payments toward deductibles, copays, coinsurance, and out-of-pocket limits and provides an HSA-safe-harbor for such counting.
Introduced December 4, 2025 by Thomas Kean · Last progress December 4, 2025
Requires group and individual health plans to count payments made by or on behalf of an enrollee — including manufacturer coupons and nonprofit patient-assistance — toward deductibles, copayments, coinsurance, and out-of-pocket limits. Creates a tax-code safe harbor so that counting these third-party payments for outpatient prescription drugs will not disqualify a high-deductible health plan (HDHP) from qualifying for health savings account (HSA) eligibility. The changes apply to plan years beginning on or after January 1, 2026 and explicitly cover specialty drugs and drugs subject to utilization management while preserving the use of utilization management tools.