119-S-864 Journalist Public Summary

Public Summary — HELP Copays Act (S. 864, 119th Congress)

Headline Summary: A bipartisan proposal to make health insurers and PBMs count copay assistance (from nonprofits or drugmakers) toward a patient’s deductible and annual out‑of‑pocket cap beginning in 2026. (congress.gov)

What It Does: The bill amends federal law so that any amounts paid by or on behalf of an enrollee—including assistance from nonprofits and prescription drug manufacturers—must be credited toward that person’s deductible, copays/coinsurance, and out‑of‑pocket maximum. It applies to specialty drugs and drugs under utilization management, and it explicitly does not change the use of tools like prior authorization or step therapy. It also creates a safe harbor so high‑deductible health plans linked to HSAs aren’t penalized for counting these payments. The changes would take effect for plan years starting January 1, 2026. (congress.gov)

Why It Matters: Today, many private plans use “copay accumulator” or similar policies that don’t count third‑party assistance toward a patient’s annual cost‑sharing. Patients using costly medicines can get hit with large, unexpected bills once assistance runs out; advocates say this can lead to people skipping treatment. This bill would stop that practice across most commercial coverage. (kff.org)

Who’s For It:

• Bipartisan Senate sponsors (Marshall, Kaine, Tillis, Markey, Murkowski, Merkley) and additional cosponsors say it will reduce out‑of‑pocket costs by ensuring all payments made on a patient’s behalf actually count. (congress.gov)
• Patient and provider coalitions (e.g., All Copays Count Coalition) argue accumulator policies create affordability shocks and threaten adherence; they back the bill to guarantee assistance is counted. (allcopayscount.org)
• Disease‑specific groups (e.g., Arthritis Foundation, bleeding‑disorders advocates) support the bill as a protection for patients who rely on expensive specialty drugs. (arthritis.org)

Who’s Against It:

• Health insurers (AHIP) contend that copay coupons are marketing tools that distort choices and raise premiums; they support accumulator policies that keep plan cost‑sharing incentives intact. (ahip.org)
• Pharmacy benefit managers (PCMA) similarly oppose bans, arguing accumulators help control drug spending and maintain incentives to use lower‑cost options when available. (pcmanet.org)

What’s Next: As of March 20, 2026, Congress.gov lists the bill as introduced and referred to the Senate HELP Committee on March 5, 2025. For it to advance, the committee would need to mark up and report the bill before any Senate floor vote, after which the House would consider it. (congress.gov)