The HELP Copays Act would change federal health insurance rules so that certain third-party financial assistance can count toward a patient’s deductible, coinsurance, copayment, or out-of-pocket limit. In practice, this means amounts paid by or on behalf of an enrollee — including assistance from nonprofit organizations and prescription drug manufacturers — would be treated as if the patient paid them directly for purposes of meeting cost-sharing obligations under group and individual health plans.
The bill also makes conforming changes to the Affordable Care Act, the Public Health Service Act, and the Internal Revenue Code. It would clarify that these counted amounts apply in the context of prescription drugs, including specialty drugs and drugs subject to utilization management, and it creates a safe harbor so high-deductible health plans would not lose their status merely because they count certain manufacturer or nonprofit assistance toward the deductible. The bill applies to plan years beginning on or after January 1, 2026.
Impact
If enacted, the bill would alter how insurers, employers, and health plans administer cost-sharing by requiring them to credit qualifying third-party assistance toward patients’ deductible and out-of-pocket thresholds. It would affect the interpretation and application of federal health coverage statutes, including ACA cost-sharing rules and high-deductible health plan requirements under the tax code, while expressly preserving utilization management tools such as prior authorization and step therapy. The practical effect would likely be lower out-of-pocket costs for some patients, especially those using expensive or specialty prescription drugs and those receiving copay assistance.
Sentiment
The bill appears to have bipartisan and cross-party support at introduction, with sponsors including Senators Marshall, Kaine, Tillis, Markey, Murkowski, and Merkley. The available context shows the bill was referred to the Senate HELP Committee and hearings were held, suggesting active consideration rather than immediate opposition. No vote totals or recorded committee debate were provided, so the overall sentiment can only be characterized as generally favorable and policy-oriented, with interest in reducing patient cost burdens.
Contention
The main policy tension is between lowering patients’ immediate out-of-pocket costs and preserving insurer cost-sharing structures. Supporters are likely to view the bill as helping patients afford expensive medications by ensuring copay assistance counts toward deductibles and annual limits, while critics may worry it could weaken cost-sharing incentives, shift costs to premiums, or complicate plan administration. The bill specifically tries to address one likely concern by stating that it does not affect utilization management tools such as prior authorization and step therapy, indicating those tools may be a point of sensitivity in the debate.
Codifies child care copayments in law, expand zero copays to families under 125% FPL, lower costs for working families, and cap most copayments at 6% while preserving a 7% statutory maximum.
Limits copays, coinsurance or office deductibles for services of a physical therapist to the amount authorized for the services of a primary care physician or osteopath on or after January 1, 2026.
Limits copays, coinsurance or office deductibles for services of a physical therapist to the amount authorized for the services of a primary care physician or osteopath on or after January 1, 2026.