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Requires private group and individual health plans to cover specified insulin products for enrollees age 26 and younger starting January 1, 2026. Plans may not impose a deductible for those insulin products and must limit cost-sharing per 30-day supply to the lesser of $35 or 25% of the negotiated price (after price concessions), with those payments counting toward deductibles and out‑of‑pocket maximums. Adds these coverage and cost-sharing rules into the Public Health Service Act, the Affordable Care Act, ERISA, and the Internal Revenue Code and authorizes HHS, Labor, and Treasury to implement the rules by guidance.
For plan years beginning on or after 2026-01-01, a group health plan or health insurance issuer offering group or individual coverage must provide coverage of selected insulin products for enrolled individuals 26 years of age or younger and comply with the cost-sharing rules in this section.
Plans shall not apply any deductible to selected insulin products for enrolled individuals 26 years of age or younger.
For selected insulin products, plans shall not impose cost-sharing in excess of the lesser of, per 30-day supply: (A) $35; or (B) an amount equal to 25% of the negotiated price of the selected insulin product net of all price concessions received by or on behalf of the plan or coverage (including concessions to third-party service providers such as PBMs).
Any cost-sharing payments made under the cost-sharing rule must be counted toward any deductible or out-of-pocket maximum that applies under the plan or coverage.
"Selected insulin products" means at least one of each dosage form (for example vial, pump, inhaler) of each different type of insulin (for example rapid-acting, short-acting, intermediate-acting, long-acting, ultra long-acting, premixed), when available, as selected by the group health plan or issuer.
Amends section 1302(d)(2) of the Patient Protection and Affordable Care Act by adding a new subparagraph (D) providing that the exemption of selected insulin products from application of a deductible shall not be considered when determining the actuarial value of a qualified health plan under subsection (d)(2).
Who is affected and how:
Enrollees age 26 and younger who use insulin: Direct beneficiaries. They will face lower out‑of‑pocket costs for the specified insulin products because plans cannot impose a deductible and cost‑sharing per 30‑day supply is capped at the lesser of $35 or 25% of the negotiated price. Those payments also count toward annual deductibles and out‑of‑pocket maximums, which can improve overall affordability.
Private health plan sponsors and issuers (including many employer self‑insured plans subject to ERISA): Must update plan documents, cost‑sharing structures, and pharmacy benefit administration to exempt the specified insulin products from deductibles and to enforce the cost‑sharing cap. This may increase plan pharmacy spending for those products and could influence premiums or plan design over time.
Pharmacies and pharmacy benefit managers (PBMs): Need to coordinate price reporting and apply the capped patient cost share per 30‑day supply. The cap is tied to negotiated price net of concessions, which may require PBMs and plans to adjust reconciliation and claims processes.
Federal agencies (HHS, DOL, Treasury): Responsible for issuing guidance and technical rules to implement the statutory changes across the ACA, ERISA, and tax rules; administrative workload is required but no new funding is specified.
Health care access and outcomes: Expected to improve short‑term access and adherence to insulin among eligible youth and young adults by lowering immediate cost barriers, potentially reducing adverse health events related to insulin underuse. Over time, plan costs may rise for affected products, with possible downstream effects on premiums or cost‑containment strategies.
States and local governments: Not directly mandated, since the law applies at the federal level to private plans, but state‑regulated insurers in the individual and small group markets will need to comply; state budgets are not directly affected unless states choose to supplement or mirror the federal requirement in public programs.
Overall, the bill is a targeted, consumer-facing coverage mandate that reduces out‑of‑pocket insulin costs for people 26 and under while shifting administrative and some financial responsibilities to plan sponsors, issuers, and PBMs. Implementation details and interactions with existing pharmacy pricing and rebate arrangements will be important for operationalizing the cost cap.
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Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Introduced April 3, 2025 by Greg Landsman · Last progress April 3, 2025
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Introduced in House