Sponsors (57)
The bill reduces patients' out-of-pocket drug costs and preserves HSA access for HDHP enrollees by counting third-party assistance toward deductibles and OOP limits (including specialty drugs), while imposing administrative costs and potential premium pressure on plans and creating incentives for manufacturers to alter assistance programs, with some short-term enrollee confusion during implementation.
People with employer or individual health plans (including many middle-class families and patients with chronic conditions) will have third-party payments from drug manufacturers or nonprofits counted toward their plan deductibles and out-of-pocket limits, directly lowering their at-the-counter costs for covered drugs.
Enrollees in high-deductible health plans (HDHPs) can use manufacturer or nonprofit assistance for outpatient prescription drugs without losing HSA eligibility because of the Internal Revenue Code safe-harbor effective for plan years after 12/31/2025.
Patients who take specialty or high-cost drugs — including those subject to utilization management — are explicitly covered so third-party assistance for these medications will count toward deductibles/OOP limits, helping people with the most expensive therapies.
Health plans and issuers will likely face increased paid claims and additional administrative burden to track and aggregate third-party assistance, which could be passed on to consumers through higher premiums or raise plan administrative costs.
Drug manufacturers may respond by changing eligibility rules or redesigning copay/assistance programs to limit their exposure, which could reduce the availability or predictability of assistance for some patients, particularly low-income or marginally eligible individuals.
Enrollees may be confused about which third-party payments count toward deductibles/OOP limits and how the transition to the new safe-harbor works in plan years beginning after 12/31/2025, risking errors or delayed access to benefits during implementation.
Based on analysis of 2 sections of legislative text.
Requires group and individual health plans to count third-party and nonprofit payments toward deductibles and out-of-pocket limits, and protects HDHP/HSA status.
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 assistance from nonprofits and prescription drug manufacturers — toward deductibles, copayments, coinsurance, and out-of-pocket limits. Also amends the tax-code safe-harbor for high-deductible health plans (HDHPs) so plans that count this assistance will not lose HSA-compatible status for plan years after Dec 31, 2025. Applies to specialty drugs and drugs subject to utilization management while preserving the use of utilization management tools. The changes take effect for plan years beginning on or after January 1, 2026.