Section 1 Short title
This Act may be cited as the “ACA Copay Cost and Affordability for Patients Act of 2025” or the “ACA Copay CAP Act of 2025”.
ACA Copay Cost and Affordability for Patients Act of 2025
A BILL
To amend the Patient Protection and Affordable Care Act to establish an out-of-pocket limit on spending for prescription drugs.
Sec. 2 Establishing an out-of-pocket limit on spending for prescription drugs
In general— Section 1302(c) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(c)) is amended—
by inserting after paragraph (1) the following new paragraph:
“(2) Annual limitation on cost-sharing for drugs
“(A) In general—The annual cost-sharing incurred under a health plan with respect to prescription drugs dispensed during a plan year beginning on or after January 1, 2027, shall not exceed the dollar amount specified in subparagraph (B) with respect to such plan year.
“(B) Amount specified—For purposes of subparagraph (B), the dollar amount specified in this subparagraph with respect to a plan year is the following:
“(i) With respect to self-only coverage—
“(I) for plan years beginning in 2027, $2,000; and
“(II) for plan years beginning in 2028 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 and the premium adjustment percentage under paragraph (4) for the calendar year.
“(ii) With respect to coverage other than self-only coverage, for plan years beginning in 2027 or a subsequent calendar year, twice the amount in effect under clause (i) for such plan year.”
in paragraph (4)—
by striking “paragraph (1)(B)(i)” and inserting “paragraphs (1) and (2)”; and
by striking “(as determined by the Secretary)” and inserting “(or, for purposes of paragraph (2), for 2027), as determined by the Secretary”.
Conforming amendments—
PPACA— Section 1302(e)(1)(B)(i) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(e)(1)(B)(i)) is amended by inserting “and except, with respect to plan years beginning on or after January 1, 2027, in the case of an individual who has incurred cost-sharing expenses with respect to prescription drugs in an amount equal to the limitation in effect under subsection (c)(2) for such plan year, for benefits consisting of prescription drugs” after “section 2713”.
PHSA— Section 2707(b) of the Public Health Service Act (42 U.S.C. 300gg–6(b)) is amended by inserting “or (2)” after “paragraph (1)”.