The HELP Copays Act mandates that financial assistance from non-profits and drug manufacturers must count toward a patient's deductible, copay, and out-of-pocket maximum for prescription drugs.
Thomas Kean
Representative
NJ-7
The HELP Copays Act requires that financial assistance provided by non-profit organizations and drug manufacturers must count toward a patient's deductible, copayments, and out-of-pocket maximums for prescription drugs. This change ensures that patient assistance dollars directly reduce the amount a patient must pay before their coverage fully kicks in. The legislation specifically applies to specialty drugs and those subject to utilization management. These provisions will take effect for plan years beginning on or after January 1, 2026.
New HELP Copays Act Mandates Drug Manufacturer Assistance Counts Toward Patient Deductibles Starting in 2026
The Help Ensure Lower Patient Copays Act, or the HELP Copays Act, is taking a direct shot at one of the most frustrating hidden costs in healthcare: the practice of insurers refusing to count third-party financial assistance toward your annual deductible or out-of-pocket maximum. Simply put, this bill mandates that any financial help you get from a non-profit or a drug manufacturer for your prescription costs must be included when calculating how much you’ve spent toward your annual deductible, copayment, coinsurance, and out-of-pocket limit.
The 'Specialty Drug' Loophole Closer
This change isn't a blanket rule for every single pill bottle, but it focuses on the areas where patients get hit the hardest. The bill specifically targets high-cost medications: prescription drugs that are classified as specialty drugs or those that require utilization management, like prior authorization or step therapy. Think of expensive injectables for chronic conditions or specialized cancer treatments. Currently, many insurers use 'copay accumulator' programs that effectively pocket the manufacturer assistance without helping the patient reach their deductible. This meant a patient could receive thousands in assistance but still have to pay the full deductible out of pocket later. The HELP Copays Act shuts down this practice, ensuring that every dollar of assistance counts toward the patient’s financial responsibility, effective for plan years beginning on or after January 1, 2026.
What This Means for Your Wallet
For anyone managing a chronic condition that requires a high-cost medication, this is a major win for budgeting. If you have a $5,000 deductible and a drug manufacturer provides a $3,000 assistance card, that $3,000 will now immediately count toward your deductible. This means you only have $2,000 left to pay before your insurance starts picking up the tab, and you’ll hit your annual out-of-pocket maximum much faster. This is especially crucial for the estimated 49% of Americans with high-deductible health plans (HDHPs).
To make sure this change works smoothly, the bill includes a technical fix for HDHPs. It creates a 'safe harbor' amendment to the Internal Revenue Code, ensuring that HDHPs can count this financial assistance toward a patient's deductible without losing their favorable tax status. This regulatory clarity is key for plan administrators and ensures HDHP enrollees aren't penalized for receiving necessary financial aid.
The Fine Print: What Doesn't Change
While the financial relief is significant, it’s important to note what the bill leaves untouched. The text explicitly states that this act does not impact the use of utilization management tools, such as prior authorization and step therapy. This means while the financial barrier might be lowered, the administrative hurdles remain. You might still have to wait for your insurance company to approve the drug, or try a cheaper, less effective drug first (step therapy), even if the manufacturer is ready to help cover the cost of the optimal medication. The fight for access continues, even as the fight for affordability sees a victory.