Counting patient payments toward deductibles

Summary#

This bill would require group and individual health plans to count money paid by or for a patient — including help from non-profit groups and drug makers — toward that patient’s deductible, coinsurance, copay, and out‑of‑pocket limit. The goal is to reduce what patients owe at the pharmacy or while meeting their cost‑sharing requirements. The rule applies starting with plan years that begin on or after January 1, 2026.

  • Main change: Payments made by or on behalf of an insured person (including non‑profit assistance and manufacturer assistance) must be treated as satisfying deductible, copay, coinsurance, and out‑of‑pocket limits.
  • Applies to prescription drugs, including specialty drugs and drugs subject to utilization management.
  • Preserves utilization management tools: The bill says it does not affect prior authorization or step therapy.
  • HSA safe harbor: Counting manufacturer or charity payments toward deductibles will not by itself make a plan fail to qualify as a high‑deductible health plan for HSA eligibility.
  • Effective date: Plan years beginning on or after Jan 1, 2026.
  • What is unclear: The bill does not give detailed rules for how plans must verify, accept, or record third‑party payments at pharmacies or how to handle different kinds of assistance programs in practice.

What it means for you#

  • Patients / People who buy insurance: If you get help from a drug company or a charity to pay a copay or other cost, that help would count toward your deductible and out‑of‑pocket maximum. This could mean you reach your deductible or out‑of‑pocket limit sooner and owe less overall that year.
  • People using manufacturer coupons or patient assistance: Those payments should be counted by the plan toward cost‑sharing limits.
  • HSA account holders: Plans that count these outside payments toward deductibles will still be allowed to qualify as high‑deductible health plans for HSA rules under the bill’s safe harbor.
  • Employers and plan sponsors: Insurers and plan administrators must adjust their accounting and plan materials to count external payments as meeting member cost‑sharing. That may require new processes with pharmacies and vendors.
  • Health insurers and issuers: Insurers must treat third‑party assistance as plan‑counting payments for deductibles and out‑of‑pocket limits. They must do this for drugs including specialty drugs and drugs subject to utilization management.
  • Non‑profit assistance programs and drug manufacturers: Their payments are explicitly included in what must be counted toward enrollees’ cost‑sharing.

Expenses#

No publicly available information.

  • The bill does not include a fiscal note in the provided text.
  • Possible administrative costs for insurers and plan administrators to change systems and agree procedures with pharmacies.
  • Insurers may face higher measured payments toward member cost‑sharing, which could affect plan finances. Any effects on premiums, plan design, or employer contributions are not estimated in the bill text.
  • The safe harbor for HDHPs may avoid costs or confusion related to HSA eligibility for some plans.

Proponents' View#

  • The bill appears intended to reduce what patients pay out of pocket by ensuring outside help (charities, coupons) counts toward deductibles and out‑of‑pocket limits.
  • Supporters may argue this would improve access to medicines by lowering immediate costs at the pharmacy.
  • The change could make patient assistance work more effectively because the money would directly reduce patients’ progress toward coverage limits.
  • The HSA safe harbor keeps people eligible for HSAs even when assistance counts toward the deductible.

Opponents' View#

  • One concern is that the bill does not explain how plans should verify and apply third‑party payments in daily pharmacy operations. This could create administrative difficulty and delay.
  • The bill may raise questions about overall costs: counting external assistance toward cost‑sharing could change incentives for insurers, employers, and manufacturers. For example, insurers or employers might alter plan design or premiums in response, but the bill does not address those follow‑on effects.
  • It is possible (but not certain from the text) that manufacturers or charities could change or reduce assistance programs if the payments must be treated as reducing patient cost‑sharing; the bill does not address such behavioral responses.
  • The bill does not set enforcement details or reporting rules, so it is unclear how disputes about whether an amount counts would be resolved.