Sponsors (28)
Requires health plans to count third‑party copay and financial assistance toward deductibles, copays, coinsurance, and out‑of‑pocket limits and creates an HSA/HDHP tax safe harbor.
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
The bill reduces patient out‑of‑pocket spending and preserves HSA access by counting third‑party assistance toward cost‑sharing, but it may raise plan costs and prompt reduced manufacturer aid or stricter insurer controls that could limit access for some patients.
Patients with chronic conditions and low‑income individuals will have manufacturer or nonprofit assistance counted toward their deductibles and cost‑sharing, reducing their out‑of‑pocket spending for covered drugs and services.
Enrollees with high specialty‑drug costs (including Medicaid beneficiaries) will reach out‑of‑pocket maximums sooner, limiting catastrophic spending on expensive therapies.
Middle‑class families and people using high‑deductible health plans will retain access to Health Savings Accounts because the bill clarifies a safe harbor allowing third‑party assistance to count toward cost‑sharing without disqualifying HSAs.
Employers and insurers may face higher short‑term plan costs, which could translate into higher premiums or altered plan designs that affect middle‑class families and other covered workers.
Patients with chronic conditions and low‑income individuals could see reduced availability of manufacturer or nonprofit assistance if those programs are scaled back or restructured in response to payments being applied to patient cost‑sharing.
Patients with chronic conditions may face increased administrative hurdles—such as tighter utilization management or prior authorization—if insurers adopt stricter controls to limit costs.
Based on analysis of 2 sections of legislative text.
Counts payments made by or on behalf of an insured person — including financial assistance from nonprofits and drug manufacturers — toward that person’s deductible, coinsurance, copayments, and out‑of‑pocket maximum for both individual and group health plans. It also adds a safe harbor in the tax code so plans that count this assistance won’t lose high‑deductible health plan (HDHP) status for health savings account (HSA) purposes. The rule applies to plan years beginning on or after January 1, 2026, clarifies that it covers specialty drugs and drugs subject to utilization management, and preserves common utilization management tools such as prior authorization and step therapy.