Summary
Big Picture. The House is in recess until August 31, while the Senate is scheduled to depart at the end of this week and return on September 7. Before recessing, the Senate will attempt to pass a continuing resolution (CR) (text, section-by-section) that funds the government through December 11. The Senate is scheduled to vote on the CR today. The bill prevents the Office of Management and Budget (OMB) rule on federal grants from going into effect and includes a provision that requires OMB to submit a report on all recissions and cancellations that continue under the CR. Senate Minority Leader Schumer (D-NY) expressed support for the bill as a “responsible path forward that allows continued bipartisan negotiations.” The House passed a clean CR before recessing that funded the government through December 4
Health Policy to Watch. Additionally, during this August period, Impact Health Policy Partners will provide a series of brief policy outlooks examining key priority areas likely to shape the health policy landscape this fall. This week, we are examining Medicare Advantage, prior authorization, and prescription drugs.
Medicare Advantage
The House Energy and Commerce Committee recently advanced several bills that address transparency in Medicare Advantage (MA) including transparency of supplemental benefits, medical loss ratio, as well as the Improving Seniors’ Timely Access to Care Act which establishes prior authorization requirements (Impact summary). These were wrapped into the Lower Costs, More Transparency Act, which will serve as the House’s health care package moving toward the end of the year. If Congress does choose to pursue a broader health care package at the end of the year, MA could be targeted as an offset. Bills like the Save MEDICARE Act (H.R. 9544), and the No UPCODE Act (S. 1105), would generate savings by addressing overpayments to MA plans.
On the regulatory side, the Clover Health v HHS court decision is dramatically impacting Star Ratings and the Quality Bonus Program. With the contract year (CY) 2028 MA and Part D policy and technical changes proposed rule arriving early at the Office of Management and Budget (OMB) for review this year, we could potentially see a major overhaul of MA’s Star Ratings and quality bonus program.
Prior Authorization
Conversation on the Hill about prior authorization is picking up as part of the conversation about potential health care legislation. Recent committee activity on prior authorization includes:
- The Senate Finance Committee Democrats’ request for information (RFI) on private insurance reforms includes a request for input on potential reforms to prior authorization, including imposing limitations or bans in certain circumstances, introducing a shared risk model, and replacing the existing system with third-party evaluators.
- The House Energy & Commerce Committee marked up a handful of health care bills, many of which they wrapped into the Lower Costs, More Transparency Act (H.R. 9393), including:
- The Improving Seniors’ Timely Access to Care Act (H.R. 3514) which requires MA organizations to establish electronic prior authorization programs and meet certain beneficiary protection and reporting requirements.
- The Prior Authorization Accountability Act (H.R. 9396) would require commercial insurers to publicly report information including approval and denial rates, appeal outcomes, response times, and the use of AI or other automated decision making in prior authorization determinations.
- The Ways & Means Committee also advanced the Improving Seniors’ Timely Access to Care Act.
Issues with prior authorization have also gained attention due to criticism of the Centers for Medicare and Medicaid Innovation (CMMI) Wasteful and Inappropriate Service Reduction (WISeR) Model that tests the use of technology-enabled prior authorization for a select set of services in Traditional Medicare. The model has been live since January, but has faced significant pushback from Democrats and some patient and provider advocates who are concerned about delaying or denying care. A Congressional Review Act challenge to the model failed along party lines, but several groups of Democrats have sent questions requesting updates on model implementation and there is an ongoing lawsuit alleging that CMS failed to be transparent and respond to a Freedom of Information Act request. The agency maintains that early implementation involved some learning and adjustments, but that the model is working as intended to speed approvals, block unsupported services, and reduce administrative burden.
Prescription Drugs
While President Trump has called for the codification of his Most Favored Nation (MFN) drug pricing policies, Congressional support has been relatively limited among Republicans, with Sen. Josh Hawley (R-MO) being one of the lone Republicans to sponsor such legislation. However, we have seen support growing for bills that would increase biosimilar competition, such as the Biosimilar Red Tape Elimination Act (S. 1954/H.R. 5526) and the Expedited Access to Biosimilars (S. 1414, H.R. 9661), which have been marked up in both chambers.
Administratively, CMS recently released the notice to implement the 340B Rebate Model Pilot Program (Impact summary) and continues to implement the Medicare Drug Price Negotiations Program, with the final rule codifying the regulations on the horizon. However, uncertainty remains regarding the GLOBE and GUARD Models, with both final rules currently pending at OMB. President Trump is also likely to continue touting his Most Favored Nation deals, as well as TrumpRx.