H.R. 8270: Every Dollar Counts Act of 2026

The Every Dollar Counts Act of 2026 aims to make changes regarding how out-of-pocket expenses for medications count towards health insurance deductibles and out-of-pocket maximums. The bill proposes the following key amendments to existing laws:

1. Counting Drug Costs Towards Deductibles

The bill requires that health insurance plans, including group health plans and individual health insurance coverage, must count any out-of-pocket expenditures made by individuals who choose to purchase medication without using their insurance benefits towards their deductible and out-of-pocket maximum. This applies to cases where the medication is covered by the insurance plan but benefits are not utilized at the time of purchase.

2. Implications for the Public Health Service Act

Specifically, under the Public Health Service Act, a new section would be added that mandates group health plans and health insurance issuers to consider these out-of-pocket drug costs in the calculation of what the individual owes before reaching their deductible or maximum spending limit.

3. Adjustments to the Employee Retirement Income Security Act (ERISA)

The bill also amends the Employee Retirement Income Security Act of 1974 to introduce a similar requirement for group health plans under ERISA, ensuring that any out-of-pocket expenditures on drugs count towards deductibles and out-of-pocket limits for participants or beneficiaries in those plans.

4. Changes to the Internal Revenue Code

Furthermore, the Internal Revenue Code is set to be amended similarly, obliging group health plans to recognize these expenditures for individuals purchasing medications outside of their insurance benefits.

5. Conforming Amendments

To align with these changes, various sections of the Social Security Act related to pricing and manufacturer pricing will also be revised to reflect and support the new counting of out-of-pocket drug costs. This includes clarifications on how reductions in drug pricing should be applied when benefits are not used.

6. Effective Date

The amendments proposed in the bill will come into effect for plan years starting on or after January 1, 2027.

Relevant Companies

• PFE - Pfizer Inc.: As a major pharmaceutical company, changes in deductible counting could impact how their drugs are priced and reimbursed under health plans.
• MRK - Merck & Co.: Similar to Pfizer, any changes regarding drug costs and insurance reimbursements could affect sales and pricing strategies.
• NVS - Novartis AG: As a supplier of a wide range of medications, the counting of out-of-pocket expenses towards deductibles may influence patient access to their products.