HELP Copays Act
- Bill Number
- S. 864
- Origin Chamber
- Senate
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2026-03-19: Committee on Health, Education, Labor, and Pensions. Hearings held.
- Last Updated
- 2026-06-24T11:03:28Z
AI-Generated Summary
Purpose
The "Help Ensure Lower Patient Copays Act" (HELP Copays Act) aims to make health insurance more affordable by ensuring that financial assistance from non-profit organizations and prescription drug manufacturers counts toward patients' cost-sharing requirements, such as deductibles (the amount you pay before insurance kicks in), copayments (fixed fees for services), coinsurance (your share of costs after deductible), and out-of-pocket limits (the maximum you pay in a year).
Key Provisions
- Inclusion of Financial Assistance in Cost-Sharing Calculations: Amends the Public Health Service Act (PHSA) to redefine key terms so that payments made by or on behalf of an individual—including aid from nonprofits and drug makers—count toward deductibles, copayments, coinsurance, and out-of-pocket limits for health plans.
- Conforming Changes to Related Laws:
- Updates the Patient Protection and Affordable Care Act (PPACA, often called Obamacare) to apply these rules to essential health benefits and similar charges.
- Modifies PHSA provisions on cost-sharing limits for prescription drugs, treating them as part of essential health benefits.
- Adds a "safe harbor" rule to the Internal Revenue Code, allowing high-deductible health plans (often paired with Health Savings Accounts, or HSAs) to count such assistance toward minimum deductibles without losing tax-advantaged status, starting after December 31, 2025.
- Rule of Construction: These changes apply to specialty drugs (high-cost medications for complex conditions) and drugs under utilization management (tools like prior approval or step therapy to control use), but do not restrict insurers' ability to use those management tools.
- Effective Date: Applies to group health plans and health insurance issuers for plan years starting on or after January 1, 2026.
Significant Changes to Existing Law
- Previously, financial assistance from third parties (like drug manufacturer coupons or nonprofit aid) often did not count toward cost-sharing limits under PHSA, PPACA, and tax rules, potentially leaving patients with higher effective costs.
- This bill explicitly includes such assistance in calculations, closing a gap that could exclude it from meeting deductibles or limits.
- Introduces a tax code safe harbor to protect HSA-eligible plans, which was not previously addressed, preventing plans from being disqualified for incorporating this aid.
Potential Impacts
- On Citizens: Patients, especially those needing expensive prescription drugs, may face lower effective out-of-pocket costs, making treatments more accessible and reducing financial burdens.
- On Government Agencies: The Department of Health and Human Services (HHS) and Internal Revenue Service (IRS) may need to update regulations and guidance to implement these standards, potentially increasing administrative oversight of health plans.
- On Health Insurance and Plans: Insurers and employers offering group plans might adjust plan designs to account for third-party aid, possibly leading to more competitive or affordable options, though it could slightly reduce their revenue from cost-sharing.
- No Apparent International Relations Impact: The bill focuses on domestic U.S. health insurance and tax rules.
Main Stakeholders Affected
- Patients and Enrollees: Primary beneficiaries, particularly those with chronic conditions relying on specialty drugs or manufacturer assistance programs.
- Health Insurance Issuers and Group Health Plans: Must comply with new calculation standards, affecting how they structure coverage.
- Non-Profit Organizations and Prescription Drug Manufacturers: Their financial aid programs become more valuable, as contributions directly reduce patients' counted costs.
- Employers: Sponsors of group plans may see indirect benefits through lower employee healthcare costs but could face plan redesign needs.
- HSA Holders: Gain flexibility in high-deductible plans without tax penalties.
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens patient protections under PHSA and PPACA by aligning third-party aid with cost-sharing rules, potentially reducing disputes over what counts toward limits; the safe harbor provision clarifies tax treatment to avoid IRS challenges.
- Constitutional: No direct implications, as it operates within Congress's authority to regulate interstate commerce and health policy.
- Political: Bipartisan sponsorship (from senators across parties) suggests broad appeal for affordability measures; could encourage similar expansions of assistance programs without altering utilization controls, balancing consumer and industry interests.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (26)
Sen. Kaine, Tim [D-VA], Sen. Tillis, Thomas [R-NC], Sen. Markey, Edward J. [D-MA], Sen. Murkowski, Lisa [R-AK], Sen. Merkley, Jeff [D-OR], Sen. Capito, Shelley Moore [R-WV], Sen. Coons, Christopher A. [D-DE], Sen. Budd, Ted [R-NC], Sen. Murray, Patty [D-WA], Sen. Boozman, John [R-AR], Sen. Shaheen, Jeanne [D-NH], Sen. Padilla, Alex [D-CA], Sen. Gallego, Ruben [D-AZ], Sen. Peters, Gary C. [D-MI], Sen. Kelly, Mark [D-AZ], Sen. Blumenthal, Richard [D-CT], Sen. Rounds, Mike [R-SD], Sen. Schiff, Adam B. [D-CA], Sen. Booker, Cory A. [D-NJ], Sen. Whitehouse, Sheldon [D-RI], Sen. Bennet, Michael F. [D-CO], Sen. Heinrich, Martin [D-NM], Sen. Husted, Jon [R-OH], Sen. Gillibrand, Kirsten E. [D-NY], Sen. Smith, Tina [D-MN], Sen. Warnock, Raphael G. [D-GA]
Recent Actions
- 2026-03-19: Committee on Health, Education, Labor, and Pensions. Hearings held.
- 2025-03-05: Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
- 2025-03-05: Introduced in Senate
Bill Versions
- Help Ensure Lower Patient Copays Act — issued 2025-03-05 — PDF (5 pages)