News

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

legislation

Washington lawmakers pass tax increase impacting insurers

Since returning in January, Washington lawmakers have been busy advancing a variety of tax increases to help manage significant budget shortfalls and introduce new revenue streams. One new source of revenue approved by both the Senate and House and included in the state’s budget is HB 2487, which removes a tax exemption for health plan-affiliated […]
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April 15, 2026

EGWP marketplace medicaid Medicare

legislation

Kentucky legislature moves to veto session

Following a flurry of legislative activity, the Kentucky General Assembly has now moved into its Veto Recess, during which Gov. Andy Beshear (D) must either sign into law or veto each of the bills the legislature sent to him. Lawmakers will return on April 14 and 15 for the final two days of the 2026 […]
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April 15, 2026

medicaid

legislation

Minnesota AI and Utilization Review Bill advances in Senate Policy Committee

Legislation introduced to address the use of AI when conducting utilization reviews was passed by the Senate Judiciary and referred to Senate Commerce and Consumer Protection Committee. Overall, the bill would ban the use of AI tools in all utilization and prior authorization reviews performed by health plans or their vendors. To date, the bill’s […]
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April 15, 2026

EGWP marketplace medicaid Medicare

legislation

White House issues new federal AI framework

On March 20, the White House released a national Artificial Intelligence (AI) Policy Framework intended to guide Congressional action on AI legislation. The framework reflects the Administration’s deregulatory approach to AI and seeks to establish a single, minimally burdensome national standard that would preempt state AI laws viewed as restrictive or inconsistent with federal policy. […]
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April 15, 2026

EGWP marketplace medicaid Medicare

legislation

FTC creates health care task force

On March 20, the Federal Trade Commission (FTC) announced the formation of a new Healthcare Task Force aimed at strengthening oversight, enforcement, and policy coordination across the health care industry to help protect American patients, health care workers, and taxpayers. In a directive issued by Chairman Andrew Ferguson, the agency is bringing together its Bureaus […]
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April 15, 2026

EGWP marketplace medicaid Medicare

legislation

E&C Committee holds hearing on Medicare and Medicaid fraud

On March 17, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing titled, “Protecting Patients and Safeguarding Taxpayer Dollars: The Role of CMS in Combatting Medicare and Medicaid Fraud.” During the hearing, members agreed that fraud in federal health care programs is a serious problem but diverged on whether current oversight efforts are politically […]
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April 15, 2026

medicaid Medicare

legislation

CMS releases MA and Part D Final Rule and Rate Notice for 2027

The Center for Medicare & Medicaid Services (CMS) recently finalized two Medicare Advantage (MA) payment and policy rules. The Final MA Rate Announcement closely aligns with Cigna’s priorities for maintaining stability, predictability, and payment accuracy across Part D markets. CMS finalized several Cigna-supported policies, including bid-based prospective Employer Group Waiver Plan (EGWP) reinsurance, separate drug […]
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April 15, 2026

EGWP Medicare

legislation

New tariffs on patented drugs and APIs announced

On April 2, President Trump announced new Section 232 tariffs on certain imported patented drugs and active pharmaceutical ingredients (APIs). The announcement follows a year-long investigation into the national security implications of importing drugs. Section 232 of the Trade Expansion Act allows the U.S. government to impose tariffs on goods seen as critical to national […]
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April 15, 2026

EGWP marketplace medicaid Medicare

legislation

Virginia governor considers PDAB and PBM legislation

Gov. Abigail Spanberger (D) is expected to sign legislation that would establish a Prescription Drug Affordability Board (PDAB). Numerous versions of this bill have been introduced in Virginia for the past five years but have either stalled in the legislature or been vetoed by Spanberger’s Republican predecessor. The proposed legislation would create a PDAB panel […]
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April 15, 2026

EGWP marketplace medicaid Medicare

legislation

Virginia and Hawaii Introduce PDAB Legislation

Gov. Abigail Spanberger (D) is expected to sign legislation that would establish a Prescription Drug Affordability Board (PDAB). Numerous versions of this bill have been introduced in Virginia for the past five years but have either stalled in the legislature or been vetoed by Spanberger’s Republican predecessor. The proposed legislation would create a PDAB panel […]
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February 12, 2026

EGWP marketplace medicaid Medicare

legislation

DOL Issues Proposed Rule on Improving Transparency into PBM Fees

Pursuant to President Trump’s Executive Order “Lowering Drug Prices by Once Again Putting Americans First,” the Department of Labor’s (DOL’s) Employee Benefits Security Administration (EBSA) issued a proposed rule that would require providers of PBM services and affiliated entities of brokerage and consulting services to disclose direct and indirect compensation to their self-funded ERISA fiduciary […]
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February 12, 2026

EGWP marketplace medicaid Medicare

legislation

CMS Releases 2027 Advance MA and Part D Rate Notice

On Jan. 26, the Centers for Medicare & Medicaid Services (CMS) released the CY2027 Medicare Advantage (MA) and Part D Advance Notice which provides preliminary estimates of payment changes in county benchmarks and proposes additional policies for the upcoming contract year. CMS projects a net average year-over-year payment increase of 0.09% (essentially flat) – a […]
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February 12, 2026

Medicare

legislation

CMS Announces Selection of Drugs for Third Cycle of the Medicare Drug Price Negotiation Program

On Jan. 27, CMS announced the 15 drugs selected for the third cycle of negotiations under the Medicare Drug Price Negotiation Program. This is the first negotiation cycle for which Part B drugs were eligible to be selected in addition to Part D drugs. The drugs selected treat conditions such as asthma, Type-2 diabetes, arthritis, […]
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February 12, 2026

Medicare

legislation

CMMI Introduces New Drug Pricing and Chronic Care Models

Since late December, the Center for Medicare and Medicaid Innovation (CMMI) has announced four new drug pricing and chronic care models: Global Benchmark for Efficient Drug Pricing (GLOBE); Guarding U.S. Medicare Against Rising Drug Costs (GUARD); Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model; and the Advancing Chronic Care with Effective, Scalable […]
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February 12, 2026

EGWP medicaid Medicare

legislation

Mississippi Considers Alternative Association Health Plan Regulation

Mississippi legislators introduced a bill that would allow professional or trade associations in the state to offer their members health benefit coverage through self-funded plans regulated by another state’s insurance department or the federal government, rather than solely Mississippi’s insurance regulations. To qualify for this exemption, plans would be required to demonstrate to the Mississippi […]
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February 12, 2026

EGWP marketplace medicaid Medicare

legislation

New Hampshire Lawmakers Seek Stronger PBM Reform

Legislators in New Hampshire are actively pursuing PBM reform through legislation and regulatory action. This year, two omnibus bills have been introduced and scheduled for hearings in January. The first bill, SB 547, would broaden the definition of a PBM to include self-funded employers and third-party administrators, including a fiduciary duty requirement between a PBM […]
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February 12, 2026

EGWP marketplace medicaid Medicare

legislation

CDC Updates Childhood Immunization Schedule

On Jan. 5, The Centers for Disease Control and Prevention (CDC) released updates to the U.S. Childhood Immunization Schedule, reducing the number of recommended vaccines from 17 to 11. The other vaccines have been recategorized as appropriate for high-risk groups or following shared clinical decision-making between providers and families. HHS and CDC stated that these […]
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February 12, 2026

medicaid

legislation

Federal PBM Reforms in Consolidated Appropriations Act Signed into Law

On Feb. 3, the U.S. House of Representatives passed the Consolidated Appropriations Act, 2026 (CAA 2026) and President Trump signed it into law shortly thereafter. The legislation includes multiple provisions relating to PBM operations that are expected to impact pharmacy benefits in both the Commercial and Medicare markets. Below are high-level details on notable provisions […]
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February 12, 2026

marketplace Medicare

legislation

Express Scripts and FTC Announce Settlement

On Feb. 4, Express Scripts and the Federal Trade Commission (FTC) announced a comprehensive resolution settlement that addresses concerns raised by the FTC. Details of the global settlement include: These are meaningful steps toward making prescription drugs more affordable for millions of families and advancing the goals we share with the administration of full transparency […]
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February 12, 2026

EGWP marketplace medicaid Medicare

legislation

Maine Ballot Initiative Underway for Universal Health Care Coverage

Through the use of a “citizen’s initiative,” efforts are underway in Maine to place on the 2026 ballot a question asking whether voters want to create state legislation to establish universal health care coverage in the state. For this to occur, at least 68,000 valid signatures must be collected by Feb. 2026. If the threshold […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

Iowa Regulator Seeks Clarity on Entities Impacted by PBM

On Oct. 14, Wellmark Blue Cross and Blue Shield filed a federal lawsuit against Iowa Insurance Commissioner Doug Ommen, challenging his enforcement of SF 383. Wellmark argues that the law violates ERISA and imposes burdensome costs and administrative requirements on health plans. The insurer’s legal action follows a previous lawsuit filed by the Iowa Association […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

Oregon to Increase Payments to Medicaid MCOs 

The Oregon Health Authority (OHA) announced that it will be increasing payments made to Medicaid Coordinated Care Organizations (CCOs) by an average of 10.2% in 2026. The increase is meant to help stabilize the Oregon Health Plan and support CCOs as they face increased financial strain due to higher utilization. OHA will also take targeted […]
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November 13, 2025

medicaid

legislation

California Governor Announces Private Label Insulin

Gov. Gavin Newsom (D) announced that California will begin selling its own brand of insulin starting Jan. 1, 2026, thanks to an agreement secured by Civica Rx, a nonprofit generic drug manufacturer, with Biocon Biologics. The CalRx insulin glargine pen, which is interchangeable with Lantus, is expected to be available to California pharmacies for $45 […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

Colorado Sued by Amgen Over PDAB Price Cap on Enbrel

Amgen, the manufacturer of Enbrel (a rheumatoid arthritis and ankylosing spondylitis treatment), filed a lawsuit against the Colorado Prescription Drug Affordability Review Board (PDAB) after the board determined Enbrel to be “unaffordable” and established an upper payment limit (UPL) of $600 per 50mg unit of the drug. In the suit, Amgen claims the UPL, which […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

State Election News in Virginia, New Jersey, and California

Tuesday’s election in Virginia went as widely expected, with Democrats winning the governor’s race as former U.S. Rep. Abigail Spanberger (D) soundly defeated Lt. Gov. Winsome Earle-Sears (R). Similar to four years ago, when Gov. Youngkin led a Republican sweep of statewide elections, Democrats swept the statewide elections this year. Voters elected Ghazala Hashmi (D) […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

Senate Hearing Draws Bipartisan Support for ACA Reforms, Unclear Path Forward

The Senate Permanent Subcommittee on Investigations held a hearing this week on “Assessing the Damage Done by Obamacare,” with testimony from Paragon Health Institute, a right-leaning think tank that has published research on alleged unauthorized enrollments and called for an end to the enhanced subsidies. Bipartisan members of the Committee expressed support for reforming the […]
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November 13, 2025

marketplace

legislation

New FDA Guidance on Approvals of Biosimilars

On Oct. 29, the Food and Drug Administration (FDA) issued new draft guidance aimed at streamlining how biosimilar and interchangeable biologics are approved. Instead of requiring extensive clinical trials, the agency is recommending a risk-based approach using advanced analytical testing and pharmacokinetic studies to support market entry of lower-cost alternatives. With biologic drugs accounting for […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

White House Announces Actions to Lower Costs and Expand Access to IVF Services

On Oct. 16, President Trump announced a MFN deal with EMD Serono. Similar to the previously announced Pfizer and AstraZeneca deals, the agreement includes the following components: 1) providing every state Medicaid program access to MFN prices on most products, 2) guaranteeing MFN prices on all new-to-market products, 3) offering certain medicines at a discounted […]
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November 13, 2025

medicaid Medicare

legislation

CMS Issues 2026 Physician Fee Schedule Final Rule

On Oct. 31, the Centers for Medicare & Medicaid Services (CMS) released the CY 2026 Medicare Physician Fee Schedule Final Rule, which outlines payment and policy updates for services furnished on or after Jan. 1, 2026, under Medicare Part B. The rule was largely finalized as proposed with some modifications. In response to stakeholder concerns, […]
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November 13, 2025

Medicare

legislation

Eli Lilly and Novo Nordisk Commit to GLP-1 Price Cuts Through MFN Deals

On Nov. 6, the Trump Administration announced new Most Favored Nation (MFN) drug pricing agreements with Novo Nordisk and Eli Lilly to lower costs for GLP-1 medications across Medicare, Medicaid, and direct-to-consumer (DTC) sales through TrumpRx. The agreements have the same key components as prior MFN deals but go a step further with lower prices […]
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November 13, 2025

medicaid Medicare

legislation

Federal Government Reopens After Longest Shutdown in History

On Nov. 12, the House passed, and the President signed into law, legislation to reopen the federal government and end the longest U.S. government shutdown in history. The agreement funds most agencies through Jan. 30, 2026, with some full-year appropriations included. Immediate impacts include federal employees returning to work and receiving back pay, resumption of […]
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November 13, 2025

EGWP marketplace medicaid Medicare

legislation

Federal Policymakers Tour Facilities in Missouri, Pennsylvania, and Tennessee

Federal policymakers recently visited Express Scripts and Accredo sites across the country to get a firsthand look at how our employees work every day to improve the health and vitality of those we serve. With the support and partnership from colleagues across the enterprise, these visits enable us to showcase our commitment to patients as […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

US-EU Announces Trade Framework Agreement

On Aug. 21, the U.S. and European Union (EU) released a long-awaited joint statement outlining a framework for an Agreement on Reciprocal, Fair, and Balanced Trade. This release follows somewhat conflicting information issued after the July 27 handshake agreement between President Trump and Commission President von der Leyen. Both sides stress that this framework is […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

Trump Signs EO to Strengthen Pharmaceutical Supply Chain

On Aug. 13, President Trump signed an executive order (EO) directing the Office of the Assistant Secretary for Preparedness and Response (ASPR) within the Department of Health and Human Services (HHS) to take steps to strengthen the domestic pharmaceutical supply chain. The EO instructs ASPR to identify 26 critical drugs vital to national health and […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

Federal Court Postpones Effective Date of Several Provisions in ACA Marketplace Integrity Rule

On Aug. 22, the U.S. District Court for Maryland issued a decision and order staying (i.e., postponing) various provisions of the recently finalized Affordable Care Act (ACA) Marketplace Integrity and Affordability Final Rule. The lawsuit, City of Columbus et al. v. Kennedy et al., was filed by a group of municipalities and nonprofit organizations and […]
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September 9, 2025

marketplace

legislation

HHS Announces 340B Drug Rebate Pilot Program

On Aug. 1, the Office of Pharmacy Affairs (OPA), which oversees the 340B program within the Health Resources and Services Administration (HRSA) at HHS, announced a new voluntary pilot program to test post-purchase rebates for drugs subject to Medicare’s Maximum Fair Price (MFP). Set to launch in 2026, the pilot allows 340B covered entities to […]
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September 9, 2025

EGWP Medicare

legislation

White House Issues Pharma Directive on MFN Drug Pricing

On July 31, President Trump issued letters to 17 drug manufacturers warning that if the companies did not take certain steps within 60 days to lower prescription drug prices, the Administration would pursue further action. The directive calls for drugmakers to voluntarily adopt a Most Favored Nation (MFN) drug pricing model for all Medicaid patients, […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

Colorado Lawmakers Adjourn Special Session; Raise Revenue

Colorado’s Special Session focused on the state’s budget shortfall of nearly $800 million and concluded with more revenue coming into the state’s coffers. Three bills of significance to The Cigna Group passed during the six-day session and are expected to be signed by Gov. Jared Polis (D). First, the legislature passed a bill that redirects […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

Pennsylvania Lawmaker Seeks Support for Vertical Integration Bill

House Representative Danilo Burgos (D) circulated a co-sponsorship memo for legislation he will be introducing to prohibit PBMs from acquiring or holding, directly or indirectly, a permit to operate a pharmacy in the Commonwealth. Rep. Burgos’ letter to his colleagues points to the bipartisan coalition of 39 state attorneys general who urged Congress to adopt […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

Arizona Governor Signs EO Joining ArrayRx Program

Gov. Katie Hobbs (D) signed an executive order to join ArrayRx, a multi-state public pharmacy collaborative that offers patients discounts on prescription drugs. Arizona joins a consortium of five other states participating in the ArrayRx PBM platform and related pharmacy savings programs. According to the governor, this action will strengthen the state’s negotiating power and […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

Wisconsin’s PBM Bill Amended, Advances from Senate Health Committee

Wisconsin’s Senate Health Committee advanced a PBM reform bill (SB 203, known as Cole’s Act) following a key amendment to remove the bill’s dispensing fee provision. This change was prompted by fiscal concerns as the provision carried a projected cost of at least $20 million annually according to the state’s budget analysis. Despite the removal […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

California Insurers and Business Groups Push Affordability Campaign

The California Association of Health Plans (CAHP) is leading an effort to raise awareness of the potential negative impacts of policy proposals under consideration by the state legislature with op-eds published in various newspapers in the state. The California Businesses for Affordable Health Care (CABAH), a CAHP funded organization, recently highlighted an op-ed in Capitol […]
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September 9, 2025

EGWP marketplace medicaid Medicare

legislation

W&M Committee Majority Highlights Report on Hospital Billing Practices

House Ways & Means Committee Republicans are amplifying a Health Affairs study that shows more urban hospitals are classifying as both rural and urban to secure higher Medicare payments and other benefits they would not otherwise be eligible for, signaling a potential focus on billing abuse. The study reports “a substantial increase in administratively ‘rural’ […]
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September 9, 2025

Medicare

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