Sponsors (27)
The bill reduces out‑of‑pocket exposure for patients by allowing third‑party drug assistance to count toward deductibles and OOP limits and preserves HSA access, but it risks higher plan costs, potential reductions in manufacturer/nonprofit aid, and tighter insurer management that could limit patient access.
Patients who rely on manufacturer or nonprofit copay/assistance programs (especially people with chronic or specialty drug needs and low‑income enrollees) will have those payments count toward their deductibles and out‑of‑pocket maximums, meaning they reach financial protections sooner and face less catastrophic drug spending.
People enrolled in high‑deductible health plans (HDHPs) and families who use health savings accounts (HSAs) keep access to HSAs because the bill clarifies a safe harbor that preserves HSA eligibility while allowing third‑party assistance to count toward cost‑sharing.
Enrollees with very high specialty‑drug costs will reach out‑of‑pocket maximums sooner when assistance counts toward cost‑sharing, reducing the duration and depth of catastrophic spending episodes.
Patients who currently rely on manufacturer or nonprofit assistance (particularly low‑income and chronically ill individuals) could see less available aid if manufacturers or nonprofits reduce, restructure, or curtail assistance programs in response to the requirement that payments be applied to cost‑sharing.
Employers and insurers may face higher short‑term plan costs from having to count third‑party payments toward cost‑sharing, which could translate into higher premiums, reduced employer contributions, or changes to plan designs that affect middle‑class families and taxpayers.
Insurers may tighten utilization management, prior authorization, or other administrative controls to manage costs, potentially making it administratively harder for some patients to obtain needed drugs even if cost‑sharing is reduced.
Based on analysis of 2 sections of legislative text.
Requires health plans to count payments from manufacturers and nonprofits toward enrollees' deductibles and out‑of‑pocket limits, with an IRC safe harbor to preserve HDHP status.
Official title: Amend title XXVII of the Public Health Service Act to apply financial assistance towards the cost-sharing requirements of health insurance plans, and for other purposes.
Introduced March 5, 2025 by Roger Wayne Marshall · Last progress March 5, 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, copays, coinsurance, and out‑of‑pocket limits. Adds an Internal Revenue Code safe harbor so applying this rule won’t disqualify plans from being treated as high‑deductible health plans for HSA eligibility; applies to plan years beginning on or after January 1, 2026.