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H 4492

Tidelands Health, 75th anniversary

2025-2026 Regular Session Introduced by Terry Alexander and 122 co-sponsors

Requires a separate prescription drug out-of-pocket limit in MA health plans, capped at the HDHP minimum annual deductible, protecting patients from high drug costs starting 2026.

Introduced and adopted
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Bill Summary · H 4492

Summary: H.4492 An Act relative to patient financial protection

Overview

H.4492, titled “An Act relative to patient financial protection,” is a Massachusetts bill introduced on September 18, 2025. It requires a separate out-of-pocket (OOP) limit for prescription drugs (including specialty drugs) within several health insurance product lines. The bill aims to cap patients’ prescription drug cost-sharing, providing clearer protection against high drug costs. It was reported favorably by the Financial Services Committee and referred to the Health Care Financing Committee. A new draft (H.1133) accompanied the bill.

What the bill does

  • Establishes a separate OOP limit specifically for prescription drugs in multiple types of health coverage, including drugs that are “specialty.”
  • The prescription drug OOP limit may not exceed the dollar amount set as the minimum annual deductible for a high deductible health plan (HDHP) under the federal Internal Revenue Code (IRC) §223(c)(2)(A)(i), for both self-only and family coverage, respectively.
  • The OOP limit is defined to include:
    • Cost-sharing expenditures under the ACA (PPACA) §1302, 42 U.S.C. §18022(c)(3)
    • Expenses related to prescription drug coverage

Key provisions by statute

  • Chapter 175 (General Laws) — Section 47AAA (new):

    • Requires every policy/contract/plan issued or renewed in Massachusetts that covers prescription drugs to establish a separate prescription drug OOP limit (including specialty drugs).
    • The OOP limit cannot exceed the HDHP minimum annual deductible amount (self-only vs. family).
    • Defines “out-of-pocket limit” to include specified cost-sharing and prescription drug-related expenses.

  • Chapter 176A (Hospital Service Plans) — Section 8EEE (new):

    • Same prescription drug OOP limit requirement as above, applied to hospital service plans.

  • Chapter 176B (Medical Service Certificates) — Section 4EEE (new):

    • Same prescription drug OOP limit requirement as above, applied to subscription certificates under medical service agreements.

  • Chapter 176G (HMOs) — Section 4WW (new):

    • Same prescription drug OOP limit requirement as above, applied to health maintenance organizations.

Who/what is affected

  • Health insurance policies, contracts, and certificates issued, delivered, or renewed in Massachusetts for:
    • Individual or group health plans covered by the listed chapters (175, 176A, 176B, 176G).
  • Plans delivered on or after January 1, 2026, are subject to these requirements.

Timelines and procedural notes

  • Effective date for the new requirements: policies delivered, issued, or renewed on or after January 1, 2026.
  • Legislative actions:
    • 2025-09-18: Reported from the Financial Services Committee
    • 2025-09-18: New draft (H.1133) referenced
    • 2025-09-18: Reported favorably by committee and referred to the Health Care Financing Committee

Potential impact and considerations

  • Pros: Potentially lower patient burdens from prescription drug costs by capping OOP expenses; consistency across various coverage types; clarity for consumers on drug-related cost-sharing.
  • Considerations: The cap is tied to federal HDHP deductibles and may fluctuate with federal thresholds; impact on premium pricing and plan design would depend on insurers’ responses and any implementing regulations.

Compiled from official sources — confirm details with the bill’s official record.

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