Requirements for the calculation of an enrollee's contribution toward cost-sharing and out-of-pocket maximum requirements set.

Minnesota House Bill HF3123, introduced on April 7, 2025, aims to change how health insurance companies and pharmacy benefit managers calculate an enrollee's contributions toward their cost-sharing and out-of-pocket maximums. Specifically, the bill requires that any payments made by the enrollee or on their behalf by another person be counted toward these limits. This includes payments for prescription drugs covered by the health plan, regardless of whether they fall under medical or pharmacy benefits. However, to maintain eligibility for Health Savings Accounts (HSAs) and catastrophic health plans under federal law, this requirement would only apply after the enrollee has met their plan deductible. If passed, the bill would take effect on January 1, 2026, and apply to health plans offered, issued, or renewed on or after that date.

Supporters of HF3123 argue that the bill promotes fairness by ensuring that all payments made toward healthcare costs, whether by the enrollee or others on their behalf, are recognized in calculating cost-sharing and out-of-pocket maximums. This change is seen as a way to alleviate financial burdens on patients, particularly those who rely on assistance programs or charitable contributions to afford their medications. By including these payments, the bill could help patients reach their out-of-pocket maximums more quickly, potentially reducing overall healthcare expenses and improving access to necessary treatments.

Critics of HF3123 express concerns that the bill could lead to increased healthcare premiums. They argue that by requiring insurers to count third-party payments toward cost-sharing limits, the overall costs to insurance companies may rise, potentially resulting in higher premiums for all policyholders. Additionally, there is apprehension that this change might encourage pharmaceutical companies to maintain high drug prices, knowing that third-party payments will help patients meet their cost-sharing requirements, thereby reducing the incentive to lower medication costs.