Establishing an out-of-pocket limit on expenditures for prescription drugs under group health plans and group and individual health insurance coverage

(a) PHSA Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended— (1) in section 2707, by adding at the end the following new subsection: (e) Sunset The preceding provisions of this section shall not apply with respect to plan years beginning on or after January 1, 2028.; and (2) in part D, as amended by section 401, by adding at the end the following new section: 2799A–13. Comprehensive coverage (a) Coverage for essential health benefits package A health insurance issuer that offers health insurance coverage in the individual or small group market shall ensure that such coverage includes the essential health benefits package required under section 1302(a) of the Patient Protection and Affordable Care Act. (b) Cost-Sharing limitation (1) In general A group health plan and a health insurance issuer offering group or individual health insurance coverage shall ensure that— (A) any annual cost-sharing imposed under the plan or coverage (including any such cost-sharing so imposed with respect to prescription drugs) does not exceed the dollar amounts specified in paragraph (2); and (B) any annual cost-sharing imposed under the plan or coverage with respect to prescription drugs does not exceed the dollar amounts specified in paragraph (3). (2) Limitation on overall out-of-pocket cost-sharing For purposes of paragraph (1)(A), the dollar amounts specified in this paragraph are the following: (A) With respect to self-only coverage— (i) for plan years beginning in 2028, the dollar amount in effect under section 1302(c)(1) of the Patient Protection and Affordable Care Act for such coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage specified in paragraph (4) of such section for the calendar year; and (ii) for plan years beginning in 2029 or a subsequent year, the dollar amount in effect under this subparagraph for plan years beginning in 2027, increased by an amount equal to the product of that amount the premium adjustment percentage specified in paragraph (4) for the calendar year. (B) With respect to coverage other than self-only coverage, for plan years beginning in 2028 or a subsequent year, twice the amount in effect under subparagraph (A) for such plan year. If the amount of any increase under subparagraph (A) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (3) Limitation on prescription drug out-of-pocket cost-sharing For purposes of paragraph (1)(B), the dollar amounts specified in this paragraph are the following: (A) With respect to self-only coverage— (i) for plan years beginning in 2028, $2,000; and (ii) for plan years beginning in 2029 or a subsequent year, the dollar amount in effect under this subparagraph for plan years beginning in 2028, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year. (B) With respect to coverage other than self-only coverage, for plan years beginning in 2028 or a subsequent year, twice the amount in effect under subparagraph (A) for such plan year. If the amount of any increase under subparagraph (A) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (4) Premium adjustment percentage For purposes of paragraphs (2)(A)(ii) and (3)(A)(ii), the premium adjustment percentage for any calendar year is the percentage (if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the Secretary no later than October 1 of such preceding calendar year) exceeds such average per capita premium for 2026 (as determined by the Secretary). (5) Cost-sharing In this section: (A) In general The term cost-sharing includes— (i) deductibles, coinsurance, copayments, or similar charges; and (ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue Code of 1986) with respect to essential health benefits covered under the plan or coverage. (B) Exceptions Such term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services. (6) Implementation The Secretary may implement the provisions of this subsection by subregulatory guidance, interim final rule, or otherwise. (c) Child-Only plans If a health insurance issuer offers health insurance coverage in any level of coverage specified under section 1302(d) of the Patient Protection and Affordable Care Act, the issuer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21. (d) Dental only This section shall not apply to a plan described in section 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act.. (b) ERISA (1) In general Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.), as amended by section 401, is further amended by adding at the end the following new section: 728. Comprehensive coverage (a) Coverage for essential health benefits package A health insurance issuer that offers health insurance coverage in the small group market shall ensure that such coverage includes the essential health benefits package required under section 1302(a) of the Patient Protection and Affordable Care Act. (b) Cost-Sharing limitation (1) In general A group health plan and a health insurance issuer offering group health insurance coverage shall ensure that— (A) any annual cost-sharing imposed under the plan or coverage (including any such cost-sharing so imposed with respect to prescription drugs) does not exceed the dollar amounts specified in paragraph (2); and (B) any annual cost-sharing imposed under the plan or coverage with respect to prescription drugs does not exceed the dollar amounts specified in paragraph (3). (2) Limitation on overall out-of-pocket cost-sharing For purposes of paragraph (1)(A), the dollar amounts specified in this paragraph are the following: (A) With respect to self-only coverage— (i) for plan years beginning in 2028, the dollar amount in effect under section 1302(c)(1) of the Patient Protection and Affordable Care Act for such coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage specified in paragraph (4) of such section for the calendar year; and (ii) for plan years beginning in 2029 or a subsequent year, the dollar amount in effect under this subparagraph for plan years beginning in 2028, increased by an amount equal to the product of that amount the premium adjustment percentage specified in paragraph (4) for the calendar year. (B) With respect to coverage other than self-only coverage, for plan years beginning in 2028 or a subsequent year, twice the amount in effect under subparagraph (A) for such plan year. If the amount of any increase under subparagraph (A) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (3) Limitation on prescription drug out-of-pocket cost-sharing For purposes of paragraph (1)(B), the dollar amounts specified in this paragraph are the following: (A) With respect to self-only coverage— (i) for plan years beginning in 2028, $2,000; and (ii) for plan years beginning in 2029 or a subsequent year, the dollar amount in effect under this subparagraph for plan years beginning in 2028, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year. (B) With respect to coverage other than self-only coverage, for plan years beginning in 2028 or a subsequent year, twice the amount in effect under subparagraph (A) for such plan year. If the amount of any increase under subparagraph (A) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (4) Premium adjustment percentage For purposes of paragraphs (2)(A)(ii) and (3)(A)(ii), the premium adjustment percentage for any calendar year is the percentage (if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the Secretary no later than October 1 of such preceding calendar year) exceeds such average per capita premium for 2027 (as determined by the Secretary). (5) Cost-sharing In this section: (A) In general The term cost-sharing includes— (i) deductibles, coinsurance, copayments, or similar charges; and (ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue Code of 1986) with respect to essential health benefits covered under the plan or coverage. (B) Exceptions Such term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services. (6) Implementation The Secretary may implement the provisions of this subsection by subregulatory guidance, interim final rule, or otherwise. (c) Child-Only plans If a health insurance issuer offers health insurance coverage in any level of coverage specified under section 1302(d) of the Patient Protection and Affordable Care Act, the issuer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21. (d) Dental only This section shall not apply to a plan described in section 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act.. (2) Clerical amendment The table of contents in section 1 of such Act, as amended by section 401, is further amended by inserting after the item relating to section 727 the following new item: Sec. 728. Comprehensive coverage.. (c) IRC (1) In general Subchapter B of chapter 100 of the Internal Revenue Code of 1986, as amended by section 401, is further amended by adding at the end the following new section: 9828. Comprehensive coverage (a) Cost-Sharing limitation (1) In general A group health plan shall ensure that— (A) any annual cost-sharing imposed under the plan (including any such cost-sharing so imposed with respect to prescription drugs) does not exceed the dollar amounts specified in paragraph (2); and (B) any annual cost-sharing imposed under the plan with respect to prescription drugs does not exceed the dollar amounts specified in paragraph (3). (2) Limitation on overall out-of-pocket cost-sharing For purposes of paragraph (1)(A), the dollar amounts specified in this paragraph are the following: (A) With respect to self-only coverage— (i) for plan years beginning in 2028, the dollar amount in effect under section 1302(c)(1) of the Patient Protection and Affordable Care Act for such coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage specified in paragraph (4) of such section for the calendar year; and (ii) for plan years beginning in 2029 or a subsequent year, the dollar amount in effect under this subparagraph for plan years beginning in 2028, increased by an amount equal to the product of that amount the premium adjustment percentage specified in paragraph (4) for the calendar year. (B) With respect to coverage other than self-only coverage, for plan years beginning in 2028 or a subsequent year, twice the amount in effect under subparagraph (A) for such plan year. If the amount of any increase under subparagraph (A) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (3) Limitation on prescription drug out-of-pocket cost-sharing For purposes of paragraph (1)(B), the dollar amounts specified in this paragraph are the following: (A) With respect to self-only coverage— (i) for plan years beginning in 2028, $2,000; and (ii) for plan years beginning in 2029 or a subsequent year, the dollar amount in effect under this subparagraph for plan years beginning in 2028, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year. (B) With respect to coverage other than self-only coverage, for plan years beginning in 2028 or a subsequent year, twice the amount in effect under subparagraph (A) for such plan year. If the amount of any increase under subparagraph (A) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (4) Premium adjustment percentage For purposes of paragraphs (2)(A)(ii) and (3)(A)(ii), the premium adjustment percentage for any calendar year is the percentage (if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the Secretary no later than October 1 of such preceding calendar year) exceeds such average per capita premium for 2026 (as determined by the Secretary). (5) Cost-sharing In this section: (A) In general The term cost-sharing includes— (i) deductibles, coinsurance, copayments, or similar charges; and (ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue Code of 1986) with respect to essential health benefits covered under the plan. (B) Exceptions Such term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services. (6) Implementation The Secretary may implement the provisions of this subsection by subregulatory guidance, interim final rule, or otherwise. (b) Dental only This section shall not apply to a plan described in section 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act.. (2) Clerical amendment The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986, as amended by section 401, is further amended by adding at the end the following new item: Sec. 9828. Comprehensive coverage.. (d) Conforming amendments The Patient Protection and Affordable Care Act (Public Law 111–148) is amended— (1) in section 1302— (A) in subsection (a)(2), by inserting with respect to plan years beginning before January 1, 2027, before limits cost-sharing; and (B) in subsection (e)(1)(B)(i)— (i) by inserting (or, with respect to plan years beginning on or after January 1, 2028, in effect under section 2799A–13(b)(1)(A) of the Public Health Service Act) after subsection (c)(1); and (ii) by inserting and except, with respect to plan years beginning on or after January 1, 2028, in the case of an individual who has incurred cost-sharing expenses with respect to prescription drugs in an amount equal to the annual limitation in effect under section 2799A–13(b)(1)(B) of such Act, for benefits consisting of prescription drugs after section 2713; and (2) in section 1402(c)(1)(A), by inserting (or, with respect to plan years beginning on or after January 1, 2028, the applicable out-of-pocket limit under section 2799A–13(b)(1)(A) of the Public Health Service Act) after section 1302(c)(1). (e) Effective date The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2028.