The "HELP Copays Act" ensures that financial assistance from non-profits and drug manufacturers counts towards a patient's deductible, coinsurance, and copay limits for health insurance plans, starting in 2026.
Roger Marshall
Senator
KS
The HELP Copays Act ensures that financial assistance from non-profits and drug manufacturers counts towards a person's deductible, coinsurance, and copay limits for health insurance plans. Beginning in 2026, this includes a "safe harbor" provision to protect high-deductible health plans. These changes apply to specialty drugs and those subject to utilization management, while still allowing the use of tools like prior authorization. The Act is effective for health plans starting on or after January 1, 2026.
HELP Copays Act Mandates Drug Coupons Count Towards Deductibles Starting 2026
The Help Ensure Lower Patient Copays Act, or HELP Copays Act, introduces a significant change to how health insurance plans handle financial assistance for prescription drugs. Effective for plan years beginning on or after January 1, 2026, this bill requires insurers to count payments made by drug manufacturers or non-profit third parties towards a patient's deductible and other cost-sharing requirements. Essentially, it aims to ensure that when you use a coupon or assistance program to lower your drug cost, that discounted amount helps you meet your annual out-of-pocket limits.
Ending the 'Accumulator' Adjustment
Currently, many health plans use 'copay accumulator' or 'maximizer' programs. These programs prevent manufacturer coupons or other third-party payments from counting towards your deductible or annual out-of-pocket maximum. The HELP Copays Act directly targets this practice. Section 2 mandates that any cost-sharing amounts paid by or on behalf of an enrollee must be applied to their limits. This includes assistance for specialty drugs and medications subject to utilization management tools like prior authorization. For example, if your plan has a $3,000 deductible and you use a $500 manufacturer coupon for a monthly medication, that $500 must now count towards hitting your deductible, potentially reducing your upfront costs significantly over the year.
Navigating High Deductibles and HSAs
The bill also addresses a tricky interaction with Health Savings Accounts (HSAs) often paired with High-Deductible Health Plans (HDHPs). Generally, to maintain HSA eligibility, individuals must meet a minimum deductible out-of-pocket before the plan covers non-preventive services. Manufacturer assistance can complicate this. The HELP Copays Act creates a specific 'safe harbor' starting in 2026: HDHPs won't lose their qualified status if they count manufacturer or non-profit assistance towards the minimum statutory deductible specifically for outpatient prescription drugs. This allows individuals in these plans to benefit from assistance programs without jeopardizing their plan's HSA compatibility for those drug costs.
The Bottom Line and Insurer Tools
While requiring assistance to count towards cost-sharing, the bill explicitly states it does not prevent insurers from using utilization management techniques. This means plans can still require prior authorization before covering a drug or ask patients to try a cheaper alternative first (step therapy). The core change is focused solely on how payments are credited after a drug is approved for coverage. This legislation aims to provide direct financial relief for patients relying on assistance for expensive medications, though the broader impact on overall insurance premiums and drug pricing strategies remains a key area to watch as the 2026 implementation date approaches.