News

Recent happenings in the regulated markets space, including updated regulatory guidance and policy changes.

legislation

Connecticut Lawmakers Pass Health Insurance and Patient Protection Act

SB 10 passed the legislature and now heads to the Gov. Ned Lamont (D) where he is expected to sign it into law. The bill would require changes regarding how insurers report mental health parity compliance to the Department of Insurance and expands drug step therapy prohibitions for patients being treated for multiple sclerosis or […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

Reconciliation Bill Signed into Law

Congress has passed and enacted the One Big Beautiful Bill Act, a sweeping tax and budget reconciliation bill, just ahead of President Trump’s deadline. The Senate approved their revised measure by a vote of 51-50, with Vice President Vance casting the tie-breaking vote. The House gave final approval to the Senate-amended version on July 3, […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

Iowa Governor Signs Law to Tighten PBM Oversight

Gov. Kim Reynolds (R) recently signed a law that restricts PBMs from steering patients to preferred pharmacies and bans the use of mandatory mail order provisions. The legislation requires PBMs to reimburse independent pharmacies at the same rate as PBMs pay their affiliated pharmacies and to pay higher dispensing fees for prescriptions. The governor included […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

Supreme Court Issues Preventive Care Decision

On June 27, the Supreme Court upheld Affordable Care Act (ACA) requirements for insurance coverage of preventive services recommended by the US Preventive Services Task Force (USPSTF), reversing the lower court’s decision. In a 6-to-3 decision written by Justice Brett Kavanaugh, the majority ruled that the appointment structure of the USPSTF, a panel of experts […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

E&C Health Subcommittee Holds Hearing on Onshoring America’s Drug Supply Chain

During a June 11 hearing on strengthening the U.S. health care supply chain, members of the House Energy and Commerce (E&C) Health Subcommittee agreed on the need to reduce reliance on foreign sources, but differed in their preferred approaches. Republicans emphasized national security and praised the Trump Administration’s deregulation and onshoring efforts, while Democrats stressed […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

CMS Finalizes ACA Marketplace Integrity and Affordability Rule 

The Centers for Medicare & Medicaid Services (CMS) finalized the 2025 Marketplace Integrity and Affordability rule, which includes a number of policies intended to address improper enrollments in Marketplace coverage and reduce improper federal spending on advanced premium tax credits (APTCs). Provisions in the rule were finalized largely as proposed with some exceptions. Effective dates […]
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July 9, 2025

marketplace

legislation

GAO Report on MA Behavioral Health Prior Authorization

On May 29, the Government Accountability Office (GAO) released a report evaluating how Medicare Advantage (MA) organizations use prior authorization (PA) and internal coverage criteria to determine beneficiary access to behavioral health services, finding that these tools frequently delay care, burden providers, and contribute to access inequities. GAO found that eight out of the nine MA […]
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July 9, 2025

Medicare

legislation

Colorado Delinking Bill Signed into Law

Gov. Jared Polis (D) signed HB 1094 into law over objections from the PBM industry and business community. The bill, which applies only to fully insured plans offered in Colorado, includes delinking, mandatory pharmacy reimbursement provisions, and additional auditing rights for payers. Delinking is a concept being pushed by pharmaceutical manufacturers to prohibit a PBM’s […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

Minnesota’s Governor Signs Omnibus Bills to End the Legislative Session

While the state was grieving the assassination of Speaker Emeritus Melissa Hortman (D) and her husband as well as the attempted murder of state Sen. John Hoffman (D) and his wife, Gov. Tim Walz (D) unceremoniously signed the Health and Human Services Omnibus bill into law. The bill includes a “single PBM model” provision to […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

HHS Releases FY26 Budget in Brief

On May 30, HHS released its FY2026 Budget in Brief outlining the Trump Administration’s health policy priorities and proposed funding levels for the upcoming fiscal year. The budget serves as a high-level summary of the department’s mandatory and discretionary spending requests. For FY2026, HHS is requesting $94.7 billion in discretionary budget authority, a significant reduction […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

FDA Voucher Plan to Reduce Drug Review Times

The FDA announced a new initiative designed to expedite the drug approval process for companies that align with U.S. national health interests. Unlike traditional review timelines of 10-12 months for final drug applications, the Commissioner’s National Priority Voucher (CNPV) program allows eligible applications to be reviewed in just 1-2 months. These vouchers will be granted […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

Illinois Lawmakers Support Governor’s PBM Tax

The legislature sent HB 1697 to Gov. Pritzker’s (D) desk, which he is expected to sign into law. The bill contains many harmful provisions, including a $15 annual tax per covered individual on PBMs. Although the bill was amended to exclude applicability to some union plans, it otherwise is broadly applicable across all lines of business […]
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July 9, 2025

EGWP marketplace medicaid Medicare

legislation

CMS Releases Final 2026 MA Policy and Technical Rule; Declines to Finalize Coverage of GLP-1s

On April 4, the Centers for Medicare & Medicaid Services (CMS) finalized the 2026 MA Policy and Technical Changes rule. Of note, CMS is not finalizing certain provisions from the proposed rule, most importantly the proposal requiring coverage of anti-obesity medications (AOMs) in both Medicare and Medicaid. CMS said that it may address these proposals […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

Budget Reconciliation Process Continues with Senate Consideration of Revised House Resolution

On April 5, the Senate voted 51-48 to pass a modified version of the House-passed budget resolution with reduced deficit reduction targets for Senate committees as compared to the House. Specific to health care, the revised Senate resolution instructs the Senate Finance Committee (SFC), which has jurisdiction over Medicaid, to propose changes that will increase […]
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April 9, 2025

medicaid

legislation

2026 Final Rate Announcement for MA and Final Part D Program Instructions

On April 7, CMS released the Calendar Year (CY) 2026 MA and Part D Final Rate Announcement and the Final CY 2026 Medicare Part D Program Instructions. The Administration strongly defended its focus on fraud, waste, and abuse, while protecting beneficiaries. The final rate notice increases average payments to MA plans by 5.06% up from […]
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April 9, 2025

EGWP medicaid Medicare

legislation

Senate Finance Committee Advances Dr. Oz’s Nomination for CMS Administrator

On March 25, the Senate Finance Committee voted 14-13 along party lines to advance the nomination of Dr. Mehmet Oz as CMS Administrator. During the confirmation hearing, Chair Mike Crapo (R-ID) and other Republicans expressed strong support for Dr. Oz, citing his prior experience as a physician and health advocate. Democrats however scrutinized the nomination. […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

HHS Announces Major Reorganization and Reduction

On March 27, the Department of Health and Human Services (HHS) announced it is restructuring in accordance with a recent executive order to reduce the size of the government’s workforce. HHS is reducing its workforce by about 10,000 full-time employees. When combined with previous HHS efforts, the restructuring results in the department downsizing from 82,000 workers […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

Bipartisan Efforts Continue to Rein in Pharma’s Patent Abuses

Lawmakers are renewing bipartisan efforts to rein in anti-competitive practices commonly used by drug manufacturers to delay market entry of lower-cost generic alternatives. Recent legislation introduced in the Senate aims to address patent thickets and product hopping practices. The Affordable Prescriptions for Patients Act, recently reintroduced by Sens. John Cornyn (R-TX), Richard Blumenthal (D-CT), Chuck […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

119th Congress Continues Momentum on PBM Reform

Both chambers of Congress are pressing forward with PBM reform efforts, reintroducing several bills that stalled in the last session. Sens. Chuck Grassley (R-IA) and Maria Cantwell (D-WA) reintroduced their bipartisan proposals to address transparency and drug pricing concerns: the Prescription Pricing for the People Act would require a federal study of industry consolidation and […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

CMS Releases 2025 Marketplace Integrity and Affordability Proposed Rule

On March 10, CMS announced a proposed rule impacting the Affordable Care Act (ACA) Marketplaces and health insurance brokers, agents, and issuers. The 2025 Marketplace Integrity and Affordability Proposed Rule includes several impactful proposals centered around eligibility, enrollment, and coverage intended to address improper enrollments in Marketplace coverage and reduce improper federal spending on advanced […]
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April 9, 2025

marketplace

legislation

Democratic Senators Demand Information on Telehealth Provider Affiliations with Eli Lilly and Pfizer

Four Democratic senators sent a letter to five telehealth companies that have held contracts with Pfizer and Eli Lilly, inquiring about their financial relationships and possible influence on prescriptions for medications. The letter was signed by the ranking member of the Senate Judiciary Committee and member of Senate Democratic leadership, Sen. Dick Durbin (D-IL), and […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

CMS Innovation Center Cancels Eight Models Ahead of New Strategy Announcement

The CMS Innovation Center (CMMI) announced on March 12 that certain payment models will be canceled or end by Dec. 31, 2025. The declaration was made after a review of the model portfolio by the Trump administration, which asserts that models must reduce spending in addition to maintaining or improving quality. The Biden administration sought […]
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April 9, 2025

EGWP medicaid Medicare

legislation

HHS Rescinds Richardson Waiver

On Feb. 28, HHS issued a policy statement announcing changes to rulemaking processes for agencies within HHS. According to the statement, HHS is rescinding a requirement – known as the Richardson Waiver – that its agencies engage in “notice-and-comment” rulemaking for matters otherwise exempted from this process under the Administrative Procedure Act (APA). While the […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

Arizona Governor Signs Formulary Bill

Legislation impacting formulary management has been signed by Arizona Gov. Katie Hobbs (D). SB 1102 prohibits a PBM from limiting or excluding coverage of a prescription drug if the drug was previously approved during the plan year and an individual continues to be an enrollee of the plan. The bill also requires impacted enrollees and […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

California’s PBM Legislation Adding More Cost on Employers

SB 41, which was vetoed by Gov. Gavin Newsom (D) last September, was amended to replace the affiliate reimbursement parity requirement with a mandatory minimum reimbursement requirement of NADAC plus the state’s Medicaid dispensing fee of $10.05-$13.20 per script. The measure, which attempts to regulate self-funded ERISA plans, already includes a host of restrictions on […]
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April 9, 2025

marketplace

legislation

New York Announces Platform to File PBM Complaints Easier

Gov. Kathy Hochul (D) recently announced the development of Department of Financial Services (DFS) Connect, a digital platform for New Yorkers to file complaints about drug price spikes. “Local small pharmacies” will also be able to use DFS Connect to seek assistance in resolving claims against PBMs. The new platform replaces an outdated system and […]
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April 9, 2025

EGWP marketplace medicaid Medicare

legislation

Connecticut Lawmakers Seek More Regulation of Stop-Loss, PBM Practices, and AI

CT legislators voted on SB 10, which would prohibit the use of stop-loss as a risk protection tool for employer plans unless the plan covers essential health benefits and state benefit mandates, or the stop-loss policy adheres to newly revised attachment points that vary based on the employer size. The bill also establishes certain prohibitions […]
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April 9, 2025

marketplace

legislation

Senators Release Site-Neutral Policy Framework

On Nov. 1, Sen. Bill Cassidy (R-LA) and Sen. Maggie Hassan (D-NH) released a legislative framework on site- neutral Medicare payment reform. The senators’ proposal includes two policy options that would cut payments to hospital outpatient departments by expanding the application of site-neutral payment policy to all hospital-owned sites of care away from the hospital’s […]
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December 10, 2024

EGWP Medicare

legislation

CMS Finalizes Physician Payment Rule

On Nov. 1, CMS finalized new policies in the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) final rule to strengthen primary care and expand access to preventive services. The rule was largely finalized as proposed. CMS finalized a 2.93% cut to physician payment, larger than the 2.8% cut projected in July. The agency […]
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December 10, 2024

EGWP Medicare

legislation

New York to Finalize PBM Regulation

The New York Department of Financial Services (DFS) has released final regulations implementing a 2022 PBM licensure law. According to DFS, this regulation will be officially finalized and effective upon its publication in the state register on Nov. 27. The final regulation follows DFS’ 2023 release of proposed regulations, which were ultimately withdrawn following vocal […]
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December 10, 2024

EGWP marketplace medicaid Medicare

legislation

Texas Legislature Begins 2025 Legislative Development

Texas lawmakers have started filing bills in preparation for the upcoming 2025 Legislative Session, even though the session does not begin until mid-January. As of this week, thousands of bills have already been filed, including bills seeking to address artificial intelligence, telehealth, abortion rights, health benefit mandates, immunizations, and drug coverage. Several bills have also […]
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December 10, 2024

EGWP marketplace medicaid Medicare

legislation

President-Elect Trump Announces Nominees for HHS, CMS and Other Key Cabinet Positions

After quickly naming his Chief of Staff and making appointments related to immigration enforcement and national security posts, on Nov. 14 President-elect Trump nominated Robert F. Kennedy, Jr. to be Secretary of Health and Human Services (HHS). Five days later he nominated television personality, heart surgeon, and Wharton graduate, Dr. Mehmet Oz to be head […]
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December 10, 2024

EGWP marketplace medicaid Medicare

legislation

CMS Releases Proposed Rule on Changes to MA and Part D Programs for CY 2026

On Nov. 26, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year (CY) 2026 Medicare Advantage (MA) and Part D Policy and Technical Changes proposed rule, which proposes numerous changes and updates to MA and Part D policies for the 2026 contract year. CMS includes proposals addressing prior authorization, utilization management, and […]
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December 10, 2024

EGWP Medicare

legislation

Louisiana Board Modifies Telehealth Rules

The Louisiana Behavior Analyst Board made positive, industry-supported changes to their proposed rulemaking. The initial proposal was very modality-restrictive, not allowing for asynchronous or audio-only delivery of care, and instead only allowing synchronous video and audio applied behavior analysis services. The reissued version of the rule conforms with the Louisiana Telehealth Act, which allows for […]
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December 10, 2024

EGWP marketplace medicaid Medicare

legislation

Washington Proposed EHB Benchmark Plan Approved by CMS

Washington’s Office of the Insurance Commissioner (OIC) recently received approval from CMS to add three new benefits to their Essential Health Benefits (EHB) benchmark plan beginning in the 2026 plan year. The benchmark plan will include an artificial insemination benefit, excluding donor semen or eggs, or services related to procuring or storing materials; coverage for […]
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December 10, 2024

EGWP marketplace medicaid Medicare

legislation

Colorado Regulator Issues Draft Rules on Transparency in Coverage and Prior Authorization

The Colorado Division of Insurance (DOI) recently issued draft regulations and held stakeholder meetings on state-level transparency in coverage reporting and prior authorization. The transparency in coverage rules, which implement Senate Bill 80 from 2024, outline carrier and PBM requirements on Colorado-specific data reporting drawn from the federal Transparency in Coverage regulations. The prior authorization […]
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December 10, 2024

EGWP marketplace medicaid Medicare

legislation

California Voters Approve Using Existing Tax for Higher Medicaid Rates

Voters in California approved Proposition 35, which makes permanent a tax on Managed Care Organizations (MCOs) and locks in much of its revenue for rate increases for many Medicaid providers, hospitals, and clinics. The measure was drafted and funded by several large health care organizations that were unhappy with how the governor and legislative budget […]
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December 10, 2024

marketplace medicaid

Initiatives

PCMA Urges CMS to Protect Financial Health of Pharmacies During IRA Implementation

On Nov. 4, PCMA called on CMS to prioritize a regulatory model where pharmacies are not at “the mercy of big drug companies” who can delay reimbursements for Medicare negotiated drugs under final Inflation Reduction Act (IRA) guidance. The group argued that “Pharmacies should not be exposed to potential financial shortfalls because of a [drug] […]
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December 10, 2024

EGWP Medicare

Guidance

Inflation Reduction Act (IRA) Educational Resources

As a means of providing additional support to our clients, the following videos and companion guides have been created to provide education and awareness to agent/brokers and customer service. This content is designed to be an educational resource for these key stakeholders to highlight recent and upcoming changes to the Medicare Part D program. This […]
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August 21, 2024

Medicare