Weekly Policy Blog: HELP Copays Act (H.R. 830)

On February 6, 2023, the federal Help Ensure Lower Patient (HELP) Copays Act (H.R. 830) was reintroduced in the U.S. House of Representatives by Representative Earl “Buddy” Carter (R-GA) and referred to the House Committee on Energy and Commerce. This bipartisan legislation requires health insurance plans regulated by the federal government to count the value of copay assistance for covered prescription drugs toward patients’ cost-sharing obligations (i.e., deductible and out-of-pocket maximum). CBSA has thanked Representative Diana DeGette (D-CO) for cosponsoring this important bill, along with Representatives Nanette Diaz Barragán (D-CA), Brian Fitzpatrick (R-PA), Mariannette Miller-Meeks (R-IA), Bonnie Watson Coleman (D-NJ), and Yvette Clarke (D-NY). 

The new H.R. 830 is essentially a reintroduction of 2021’s HELP Copays Act (H.R. 5801), which was introduced November 2021, but failed to progress out of committee. 

What does the HELP Copays Act do? 

The HELP Copays Act addresses barriers to care by fighting high out-of-pocket insurance costs for patients. The bill: 

  • Requires health insurance plans to count the value of copay assistance toward patient cost–sharing requirements; and 
  • Ends an insurer and pharmacy benefit manager (PBM) practice classifying certain medications as “non-essential” to avoid out-of-pocket maximums. 

What is copay assistance? 

Copay assistance is payment from a charity, nonprofit, or pharmaceutical manufacturer made to a pharmacy on behalf of a patient. It is designed to help offset the patient’s out-of-pocket cost for treatments and medications. 

What are copay accumulator programs? 

Many health insurance plans and PBMs have instituted copay accumulator adjustment policies, or copay accumulator programs, which block copay assistance from being counted toward a patient’s deductible or out-of-pocket maximum. These programs enable plans and PBMs to “double dip” by essentially collecting deductibles and out-of-pocket maximums twice—once from the third party providing copay assistance to the patient and again from the patient directly once the assistance runs out. 

How do copay accumulator programs harm patients? 

Copay accumulator programs harm patients by negating the longer-term benefits of copay assistance programs, which are designed to help patients by lowering the amount they have to pay out of their own pocket before their insurance benefits kick in. Copay accumulator programs force patients to incur their plans’ full out-of-pocket costs later, because, once they have exhausted copay assistance from third parties, patients are still on the hook for their entire deductible or out-of-pocket maximum before they can access insurance benefits. 

By the numbers: 

According to a 2023 report from The AIDS Institute

  • 64% of health plans offered to individuals and families through the ACA marketplaces for 2023 include a copay accumulator adjustment policy. 
  • In 24 states, over half of such plans include a copay accumulator adjustment policy. 
  • Colorado is one of 6 states where 25% – 50% of such plans include a copay accumulator adjustment policy. 

According to the All Copays Count Coalition

  • Six states and Puerto Rico have already enacted policies to ensure copay assistance counts towards patients’ out-of-pocket costs. 
  • From 2015-2020, out-of-pocket costs in the commercial market declined by 6.3% due to the use of copay assistance, leading to $12 billion in out-of-pocket savings for patients.  
  • Copay assistance leads to 1.0 to 3.3% better health outcomes by increasing drug utilization. 

Seventy-five national patient and provider advocacy groups that make up the All Copays Count Coalition (ACCC) have applauded the reintroduction of the HELP Copays Act. The Coalition’s Steering Committee is comprised of the Arthritis Foundation, the Cancer Support Community, the Immune Deficiency Foundation, the National Hemophilia Foundation, the National Multiple Sclerosis Society, and The AIDS Institute. The ACCC emphasized that the HELP Copays Act “eliminates barriers to treatment for some of the most vulnerable Americans—those who live with serious, complex chronic illness—ensuring that they can afford the necessary and often life-saving medications prescribed by their providers.” 

Categories: CBSA News