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.

Plain-English Summary

This bill changes how health insurance plans in Rhode Island calculate a person's out-of-pocket spending. Currently, when a drug manufacturer or charity provides a coupon or financial assistance to help someone pay for a medication, many insurance companies do not count that money toward the patient's deductible or out-of-pocket maximum. This means patients can receive outside help paying for a drug but still have to spend thousands of dollars out of their own pocket before their insurance kicks in. This bill would require insurance plans to count all payments made toward a patient's costs — including money paid by third parties like drug manufacturers, patient assistance programs, or charitable organizations — when tracking how close someone is to reaching their out-of-pocket limit.

Starting January 1, 2027, health insurance plans in Rhode Island would be required to apply third-party payments to a patient's cost-sharing totals, such as deductibles and out-of-pocket maximums. This means that if a drug company coupon covers part of a prescription cost, that amount would count toward what the insurance company considers the patient's annual spending threshold.

This bill primarily affects people enrolled in Rhode Island health insurance plans who take expensive medications and rely on manufacturer coupons or patient assistance programs to afford them. For these individuals, the change could mean they reach their out-of-pocket maximum sooner, reducing what they ultimately pay in a given year. Insurance companies and pharmacy benefit managers would need to update how they track and calculate enrollee spending to comply with the new requirement.