What This Bill Does
This bill changes how health insurance plans count payments toward cost-sharing requirements. It requires that when patients receive financial help like discounts, vouchers or third-party payments to reduce what they owe out of pocket, those amounts must be counted toward their deductibles, co-insurance, copayments and out-of-pocket limits.
Who It Affects
People enrolled in group health plans or individual health insurance coverage. Health insurance companies and plans offering this coverage.
Key Provisions
• Health insurance standards must include third-party payments, financial assistance, discounts, product vouchers and other reductions in out-of-pocket expenses when defining deductibles, co-insurance, copayments and out-of-pocket limits, and these amounts must be counted toward those cost-sharing requirements (Sec. 2(a))
• These same payment types must be included and counted toward deductibles, coinsurance, copayments and similar charges under plans meeting essential health benefits standards (Sec. 2(b)(1))
• The limitation on out-of-pocket costs applies to any item or service covered under a plan that falls within a category of essential health benefits (Sec. 2(b)(2))
What Changes
If this becomes law, financial help patients receive from any source must count toward their cost-sharing obligations rather than reducing the amount they can claim. This could lower what patients ultimately pay out of pocket for health care.
Important Definitions
Deductible: the amount a patient must pay before insurance coverage begins. Co-insurance: the percentage of costs a patient pays after meeting their deductible. Copayment: a fixed amount a patient pays for a specific service. Out-of-pocket limit: the maximum amount a patient must pay in a year for covered services.
Effective Date
Not specified in bill text
I
118TH CONGRESS
1ST SESSION
H. R. 830
To amend title XXVII of the Public Health Service Act to apply additional
payments, discounts, and other financial assistance towards the cost-
sharing requirements of health insurance plans, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 6, 2023
Mr. CARTER of Georgia (for himself, Ms. BARRAGA´N, Mrs. MILLER-MEEKS,
Ms. DEGETTE, Mr. FITZPATRICK, Mrs. WATSON COLEMAN, and Ms.
CLARKE of New York) introduced the following bill; which was referred
to the Committee on Energy and Commerce
A BILL
To amend title XXVII of the Public Health Service Act
to apply additional payments, discounts, and other finan-
cial 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,
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SECTION 1. SHORT TITLE.
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This Act may be cited as the ‘‘Help Ensure Lower
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Patient Copays Act’’ or the ‘‘HELP Copays Act’’.
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•HR 830 IH
SEC. 2. APPLICATION OF ADDITIONAL PAYMENTS, DIS-
1
COUNTS, AND OTHER FINANCIAL ASSIST-
2
ANCE
TOWARD
COST-SHARING
REQUIRE-
3
MENTS.
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(a) APPLICATION TOWARD COST-SHARING REQUIRE-
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MENTS.—Section 2715(g)(1) of the Public Health Service
6
Act (42 U.S.C. 300gg–15(g)(1)) is amended by adding at
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the end the following: ‘‘In developing the standards for
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defining the terms ‘deductible’, ‘co-insurance’, ‘co-pay-
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ment’, and ‘out-of-pocket limit’ (as described in paragraph
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(2)), such standards shall provide that such terms include
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amounts paid by, or on behalf of, an individual enrolled
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in a group health plan or group or individual health insur-
13
ance coverage, including third-party payments, financial
14
assistance, discounts, product vouchers, and other reduc-
15
tions in out-of-pocket expenses and that such amounts
16
shall be counted toward such deductible, co-insurance, co-
17
payment, or limit, respectively.’’.
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(b) CONFORMING AMENDMENTS.—
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(1) PPACA.—Section 1302(c)(3) of the Patient
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Protection and Affordable Care Act (42 U.S.C.
21
18022(c)(3)) is amended by adding at the end the
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following new subparagraph:
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‘‘(C) APPLICATION OF TERMS.—For pur-
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poses of subparagraph (A), the terms ‘deduct-
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ible’, ‘coinsurance’, ‘copayment’, or ‘similar
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•HR 830 IH
charge’ and any other expenditure described in
1
clause (ii) of such subparagraph shall include
2
amounts paid by, or on behalf of, an individual
3
enrolled in a group health plan or group or in-
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dividual health insurance coverage, including
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third-party payments, financial assistance, dis-
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counts, product vouchers, and other reductions
7
in out-of-pocket expenses and such amounts
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shall be counted toward such deductible, coin-
9
surance, copayment, charge, or other expendi-
10
ture, respectively.’’.
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(2) PHSA.—Section 2707(b) of the Public
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Health Service Act (42 U.S.C. 300gg–6(b)) is
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amended by adding at the end the following new
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sentence: ‘‘For purposes of the previous sentence,
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such limitation shall be applied as if the reference to
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‘essential health benefits’ in section 1302(c)(3) of
17
the Patient Protection and Affordable Care Act were
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a reference to ‘any item or service covered under the
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plan included within a category of essential health
20
benefits as described in (b)(1) of such section’.’’.
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Æ
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