H.R. 6423: Help Ensure Lower Patient Copays Act

The bill titled the "Help Ensure Lower Patient Copays Act" aims to modify health insurance regulations to allow for greater financial assistance in covering out-of-pocket costs for patients enrolled in group health plans or individual health insurance. Here’s a summary of the key provisions:

Financial Assistance Inclusion

The bill amends existing laws to specify that when establishing definitions of key terms related to health insurance costs, such as deductibles, coinsurance, copayments, and out-of-pocket limits, it will be required to include amounts that patients pay or amounts provided on their behalf. This includes:

• Financial assistance from non-profit organizations
• Assistance from prescription drug manufacturers

These amounts will be counted towards the individual’s deductible, coinsurance, copayment, or out-of-pocket limits.

Conforming Amendments

The bill also makes conforming changes to existing laws, which include:

• Amending the Patient Protection and Affordable Care Act (PPACA) to also recognize financial assistance in relation to deductibles and other expenses.
• Stipulating that limitations related to out-of-pocket expenditures for prescription drugs must reflect the inclusion of any financial assistance provided, thereby enhancing the benefits available to patients.

High Deductible Health Plans

Furthermore, the bill introduces provisions regarding high deductible health plans. It states that starting from plan years beginning after December 31, 2025, financial assistance will not prevent a health plan from being recognized as a high deductible health plan. This means that contributions towards out-of-pocket costs through assistance will count when determining if the necessary minimum deductible has been met.

Applicability

The amendments will pertain specifically to:

• Prescription drugs classified as specialty drugs
• Prescription drugs that are subject to utilization management

However, the use of tools such as prior authorization and step therapy will remain unaffected by these changes.

Effective Date

The changes proposed in this bill will take effect for group health plans and health insurance issuers for plan years beginning on or after January 1, 2026.

Relevant Companies

None found.