Includes any costs paid by an enrollee or on behalf of the enrollee by a third party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost sharing requirement under a health plan as of January 1, 2027.

Rhode Island Bill Summary: Prescription Drug Cost Sharing

This bill addresses how health insurance plans calculate the money patients spend toward their out-of-pocket maximums — the yearly cap on how much a person has to pay for covered healthcare before insurance covers everything. Specifically, it would require insurance plans to count all payments made toward a patient's costs, including money paid on their behalf by third parties like pharmaceutical manufacturer coupons or patient assistance programs. Currently, many insurance plans do not count these third-party payments, meaning patients can receive help paying for an expensive drug but still not get "credit" for that spending toward their annual out-of-pocket limit.

Starting January 1, 2027, this bill would change that rule for Rhode Island health plans. If a drug manufacturer's coupon covers part of a patient's copay, for example, the full amount paid — including the coupon value — would count toward that patient's out-of-pocket maximum. This is sometimes called ending the "accumulator adjuster" practice used by some insurance plans.

The people most directly affected are Rhode Islanders who take expensive medications and rely on manufacturer coupons or charitable assistance programs to help afford them. For these patients, the change could mean reaching their out-of-pocket maximum sooner, after which insurance covers 100% of their costs. The bill is currently being held in committee for further review, meaning lawmakers have not yet moved it forward for a full vote.