Requirements for the calculation of an enrollee's contribution toward cost-sharing and out-of-pocket maximum set.
Summary
HF4618 would require health plan companies and pharmacy benefit managers to count all amounts paid by or on behalf of an enrollee when calculating that enrollee’s progress toward cost-sharing limits and out-of-pocket maximums. The bill applies this rule to prescription drugs that are approved for coverage by the health plan, whether the drug is paid under the medical benefit or the pharmacy benefit. In practical terms, it is designed to ensure that third-party payments, including assistance paid on an enrollee’s behalf, are credited toward the enrollee’s deductible and annual spending limits.
The bill also includes a safeguard for federal tax and coverage rules. If counting those payments before the deductible is met would make an enrollee ineligible for a health savings account-qualified plan or a catastrophic health plan, the bill delays application of the rule until after the deductible is met. The proposal would take effect January 1, 2027, and would apply to health plans offered, issued, or renewed on or after that date.
Impact
The bill would add a new section to Minnesota Statutes, chapter 62Q, governing how insurers and pharmacy benefit managers calculate enrollee cost-sharing accumulation and out-of-pocket maximums. It would require plan administrators to include amounts paid directly by enrollees and amounts paid on their behalf, which could accelerate when consumers reach deductible and out-of-pocket limits for covered prescription drugs. The bill could affect health plan design, claims processing, and coordination with manufacturer assistance or other third-party payment programs, while preserving HSA and catastrophic plan eligibility where federal law would otherwise be implicated.
Sentiment
The available record does not include committee testimony or recorded votes, so there is no documented debate to gauge formal support or opposition. Based on the bill’s structure, the measure appears consumer-protective and aimed at reducing out-of-pocket burdens for people using covered prescription drugs. The inclusion of a carve-out for HSA-qualified and catastrophic plans suggests an effort to avoid unintended federal tax or coverage consequences, which may make the proposal more broadly acceptable to stakeholders.
Contention
The main policy issue is whether third-party payments, such as manufacturer assistance or other payments made on an enrollee’s behalf, should count toward deductibles and out-of-pocket maximums. Supporters would likely view the bill as preventing patients from being penalized when outside assistance helps pay for medicines, while insurers and pharmacy benefit managers may be concerned about higher plan costs, premium effects, and administrative complexity. A second point of contention is the interaction with federal HSA and catastrophic plan rules, which the bill addresses by limiting application in those circumstances.
Includes any costs paid by an enrollee or on behalf of the enrollee by a third party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost sharing requirement under a health plan as of January 1, 2026.
Includes any costs paid by an enrollee or on behalf of the enrollee by a third party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost sharing requirement under a health plan as of January 1, 2026.
Includes any costs paid by an enrollee or on behalf of the enrollee, by a third party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost sharing requirement, under a health plan as of January 1, 2027.
Includes any costs paid by an enrollee or on behalf of the enrollee by a third party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost sharing requirement under a health plan as of January 1, 2027.