II
119THCONGRESS
1
STSESSION S. 864
To amend title XXVII of the Public Health Service Act to apply financial
assistance towards the cost-sharing requirements of health insurance
plans, and for other purposes.
IN THE SENATE OF THE UNITED STATES
MARCH5, 2025
Mr. M
ARSHALL(for himself, Mr. KAINE, Mr. TILLIS, Mr. MARKEY, Ms. MUR-
KOWSKI, and Mr. MERKLEY) introduced the following bill; which was read
twice and referred to the Committee on Health, Education, Labor, and
Pensions
A BILL
To amend title XXVII of the Public Health Service Act
to apply financial assistance towards the cost-sharing
requirements of health insurance plans, and for other
purposes.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Help Ensure Lower 4
Patient Copays Act’’ or the ‘‘HELP Copays Act’’. 5
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SEC. 2. APPLICATION OF FINANCIAL ASSISTANCE TOWARD 1
COST-SHARING REQUIREMENTS. 2
(a) A
PPLICATIONTOWARDCOST-SHARINGREQUIRE-3
MENTS.—Section 2715(g)(1) of the Public Health Service 4
Act (42 U.S.C. 300gg–15(g)(1)) is amended by adding at 5
the end the following: ‘‘In developing the standards for 6
defining the terms ‘deductible’, ‘coinsurance’, ‘copayment’, 7
and ‘out-of-pocket limit’ (as described in paragraph (2)), 8
such standards shall provide that such terms include 9
amounts paid by, or on behalf of, an individual enrolled 10
in a group health plan or group or individual health insur-11
ance coverage, including financial assistance offered by 12
non-profit organizations and prescription drug manufac-13
turers, and that such amounts shall be counted toward 14
such deductible, coinsurance, copayment, or limit, respec-15
tively.’’. 16
(b) C
ONFORMINGAMENDMENTS.— 17
(1) PPACA.—Section 1302(c)(3) of the Patient 18
Protection and Affordable Care Act (42 U.S.C. 19
18022(c)(3)) is amended by adding at the end the 20
following new subparagraph: 21
‘‘(C) A
PPLICATION OF TERMS .—For pur-22
poses of subparagraph (A), the terms ‘deduct-23
ible’, ‘coinsurance’, ‘copayment’, or ‘similar 24
charge’ and any other expenditure described in 25
clause (ii) of such subparagraph shall include 26
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amounts paid by, or on behalf of, an individual 1
enrolled in a group health plan or group or in-2
dividual health insurance coverage, including fi-3
nancial assistance offered by non-profit organi-4
zations and prescription drug manufacturers, 5
and such amounts shall be counted toward such 6
deductible, co-insurance, co-payment, charge, or 7
other expenditure, respectively.’’. 8
(2) PHSA.—Section 2707(b) of the Public 9
Health Service Act (42 U.S.C. 300gg–6(b)) is 10
amended by adding at the end the following new 11
sentence: ‘‘For purposes of the previous sentence, 12
such limitation shall be applied to prescription drugs 13
as if the reference to ‘essential health benefits’ in 14
section 1302(c)(3) of the Patient Protection and Af-15
fordable Care Act were a reference to ‘any item or 16
service covered under the plan included within the 17
prescription drug category of essential health bene-18
fits as described in (b)(1)(F) of such section’.’’. 19
(3) I
NTERNAL REVENUE CODE OF 1986 SAFE 20
HARBOR FOR CERTAIN AMOUNTS APPLIED TO 21
DEDUCTIBLES.—Section 223(c)(2) of the Internal 22
Revenue Code of 1986 is amended by adding at the 23
end the following new subparagraph: 24
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‘‘(H) SAFE HARBOR FOR CERTAIN 1
AMOUNTS APPLIED TO DEDUCTIBLES .—In the 2
case of plan years beginning after December 3
31, 2025, a plan shall not fail to be treated as 4
a high deductible health plan by reason of 5
counting amounts paid by, or on behalf of, an 6
individual, including financial assistance offered 7
by non-profit organizations and prescription 8
drug manufacturers for outpatient prescription 9
drugs, when determining whether the minimum 10
deductible under subparagraph (A) has been 11
satisfied.’’. 12
(c) R
ULE OFCONSTRUCTION.—The amendments 13
made by this section shall — 14
(1) apply to standards relating to deductibles, 15
coinsurance, copayments, or limits with respect to 16
prescription drugs that are specialty drugs; 17
(2) apply to standards relating to deductibles, 18
coinsurance, copayments, or limits with respect to 19
drugs that are subject to utilization management; 20
and 21
(3) not impact the use of utilization manage-22
ment tools, including prior authorization and step 23
therapy. 24
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(d) EFFECTIVEDATE.—This section, and the amend-1
ments made by this section, shall apply to group health 2
plans and health insurance issuers for plan years begin-3
ning on or after January 1, 2026. 4
Æ
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