The HELP Copays Act moves forward – now in the Senate as well as in the House 

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Protections for people who rely on copay assistance have been a top priority for HFA and many other patient groups for several years. That effort took a big step forward in April with the introduction of a first-ever Senate version (S. 1375) of the HELP Copays Act.  

Sponsored by Sens. Kaine, Marshall, Markey, and Ernst, S. 1375 (identical to its House counterpart, H.R. 830) is bipartisan legislation that would prohibit copay accumulator adjusters. The bill would require health plans to count copay assistance towards a beneficiary’s deductible and out-of-pocket maximum. It would also close the so-called “non-essential health benefits loophole” that health plans and pharmacy benefits managers (PBMs)1 currently exploit to justify the imposition of copay maximizers. These reforms will help people with bleeding disorders and other costly health conditions to afford their medications and stay on their treatment regimens.  

The Senate Committee on Health, Education, Labor and Pensions has scheduled a markup of multiple bills relating to PBM reform on May 2, 2023. Patient advocates are asking the Committee to include the HELP Copays Act in its markup. You can add your voice, emailing your lawmakers via HFA’s easy-to-use Legislative Action Center. Please do so today! 

Quick Hits: 

  • In other PBM reform efforts, the Senate Finance Committee released a bipartisan framework to address prescription drug pricing and require more transparency from PBMs. On the House side, the Energy & Commerce held a hearing on April 26th into PBM issues, and Oversight Committee Chair James Comer launched an investigation into PBM tactics that are “harming patient care and increasing costs for consumers.”  
  • The House of Representatives narrowly passed a debt limit bill that would subject Medicaid beneficiaries to work and reporting requirements as part of an explicit effort to cut federal Medicaid spending. HFA and allied patient groups oppose such requirements, which jeopardize coverage for millions of Medicaid beneficiaries. Research shows that most non-disabled adult Medicaid beneficiaries already work or qualify for an exemption – but can easily lose coverage, under a work requirements scheme, due to onerous paperwork requirements and bureaucratic red tape. The House-passed plan is opposed by the Administration and has little chance of passing the Senate. 
  • On April 17th, the Centers for Medicare & Medicaid Services (CMS) released its Notice of Benefit and Payment Parameters for 2024 health plans. This latest iteration of the NBPP strengthens network adequacy standards and applies them to all Marketplace plans; takes steps to simplify choice and improve the plan selection process by limiting the proliferation of non-standardized plans; mandates accuracy in plan marketing names; and makes changes to the special enrollment period rules to facilitate seamless transitions into Marketplace plans for those who lose Medicaid coverage during the Medicaid “unwinding.” The NBPP, as in recent years, is silent on the topic of copay accumulator adjusters, despite patient advocates’ urgent request for protection against these harmful plan features. 
  • On April 5th, CMS issued a final Medicare Advantage regulation cracking down on misleading marketing schemes, removing barriers to care created by complex prior authorization and utilization management rules, promoting more equitable care, and expanding eligibility for the program that helps low-income seniors afford their Part D drugs (“Extra Help”). 
  • CMS proposed expanding Medicaid and Marketplace eligibility to immigrants who came to the U.S. as children but lack legal status (enrollees in DACA, the Deferred Action for Childhood Arrivals program, also known as “Dreamers”). Studies show that 47% of individuals eligible for DACA are uninsured, as compared to 10% of U.S.-born individuals in their age group. Several states, including CA, NY, and MN, already cover DACA recipients through Medicaid, while other states, including CO, already provide a pathway for DACA recipients to purchase Marketplace insurance. 
  • Finally, April was a busy month in the courts.  
    • A federal court “stayed approval” of a drug, mifepristone, that is used (among other things) in medical abortions and in the management of miscarriages. The court ruled that the U.S. Food and Drug Administration violated its own regulations and procedures when it approved mifepristone 23 years ago. Drug manufacturers, patient advocates, legal experts, and many others warn that the unprecedented ruling diminishes FDA’s authority, poses a threat to other drug approvals, and potentially jeopardizes patient access to a wide swath of FDA-approved medications. The U.S. Department of Justice promptly appealed; the Supreme Court has stayed the lower court ruling while the appeal moves forward, so mifepristone remains available for now. 
    • Patient groups including HFA filed an amicus curiae brief in litigation over the validity of the Affordable Care Act’s preventive services requirements (Braidwood v. Becerra). The patient groups urged the appeals court to put a March 30 trial court ruling on hold pending appeal, citing the devastating impact the decision will have on patient access to critical preventive care services absent a stay. 
    • Patient groups including HFA filed an amicus curiae brief urging the Fifth Circuit Court of Appeals to preserve protections for LBGTQ+ patients under the ACA’s anti-discrimination provisions.