This bill extends and modifies the premium tax credit (subsidy) for health insurance purchased through the marketplace, applying to coverage for 2026 and 2027. It raises the income threshold for full subsidy eligibility from 400% to 600% of the federal poverty level, meaning more low-to-moderate-income households (up to 600% of poverty) will pay lower monthly insurance costs. The bill also adds new penalties for agents or brokers who provide false information during enrollment, including civil fines up to $50,000 per person and criminal charges for intentional fraud. These changes directly affect individuals buying health insurance through marketplaces and the agents/brokers who assist them.
This bill extends the Affordable Care Act's premium tax credit through 2028 (instead of 2026) and raises the household income eligibility cap from 400% to 700% of the federal poverty level. It allows individuals to receive advance credit payments directly into their Health Savings Accounts (HSAs) or to their insurance issuer, depending on their plan type and election. The bill also establishes a minimum monthly premium responsibility amount for coverage and requires federal agencies to verify immigration status for tax credit eligibility. These changes primarily affect low-to-moderate income individuals purchasing health insurance through the ACA marketplace.
HR 7227, the Mental Health and MAMA Act of 2026, eliminates cost-sharing (like copays or deductibles) for mental health and substance use treatment services during pregnancy and for one year after childbirth. It directly affects pregnant and postpartum individuals covered by group health plans or individual insurance policies, requiring these plans to cover such services with no out-of-pocket costs from pregnancy diagnosis through the 12-month period following birth. The law applies to in-network providers and includes telehealth services, with implementation delayed until two years after enactment. It amends key laws including the Public Health Service Act, ERISA, and the Internal Revenue Code to standardize this coverage requirement across health insurance systems. This policy change aims to improve access to care during a critical health period without altering existing coverage definitions.
The Choose Medicare Act would establish a new Medicare Part E public health plan available across individual, small group, and large group insurance markets. This plan would provide comprehensive coverage including all essential health benefits, gold-level coverage, and reproductive services, with premiums negotiated to be at least as favorable as current Medicare rates. The bill would create a $6,700 annual out-of-pocket spending limit for Medicare beneficiaries starting in 2027, require employers to refer employees without adequate coverage to navigators, and change premium assistance credits to use gold-level plans as the benchmark. It would also establish a $2 billion startup fund for the program and expand reduced cost-sharing for lower-income individuals.
HR 6479, the Puerto Rico Affordable Care Act of 2025, would extend key provisions of the Affordable Care Act to Puerto Rico. Specifically, it requires Puerto Rico to establish a health insurance marketplace (Exchange) one year after enactment, applies federal health insurance market reforms (like banning lifetime limits) to coverage sold there, and treats Puerto Rico like a state for federal premium tax credits. This means Puerto Rico residents would gain access to the same health insurance marketplaces, consumer protections, and federal subsidies for low-income residents as those in states. The bill directly affects all Puerto Rico residents seeking health insurance coverage by aligning their access with the ACA framework.
HR 5813, the Women’s Health and Cancer Rights Modernization Act of 2025, requires health insurance plans to cover all medically necessary breast or chest wall reconstruction services following breast cancer treatment, including mastectomy or breast-conserving surgery. It mandates coverage for every reconstruction method (like implants, tissue flaps, or future recognized techniques), symmetrical surgery for the other breast, custom prostheses, and treatment of complications like lymphedema. Health plans must ensure at least one in-network provider for each reconstruction type, provide annual written notices to patients about this coverage, and cannot deny coverage or penalize providers for following these requirements. This applies to group and individual health insurance plans, with no effect on stricter state laws requiring broader coverage.
The RESTORE Act (S 1882) aims to improve reproductive health care by expanding access to restorative reproductive medicine, which focuses on diagnosing and treating underlying causes of infertility rather than solely using assisted reproductive technologies. The bill requires the Department of Health and Human Services to conduct regular literature reviews on standard care for infertility and reproductive health conditions, and to modernize medical coding to better classify and reimburse restorative treatments like laparoscopic excision for endometriosis. It also expands Title X funding eligibility for restorative medicine providers, advances education on fertility awareness-based methods, and directs the National Survey of Family Growth to collect data on reproductive health conditions. These changes primarily affect women and men with conditions like endometriosis, polycystic ovary syndrome, and uterine fibroids, as well as healthcare providers and health insurance plans. The legislation seeks to address gaps in diagnosis, treatment, and coverage for reproductive health conditions that impact 15-16% of couples experiencing infertility.
The Healthcare Freedom Act of 2025 would rename health savings accounts as "health freedom accounts" and make them available to all individuals, removing the previous requirement of having a high-deductible health plan. It increases the annual contribution limit to $12,000 (or $24,000 for joint returns) and expands eligible expenses to include direct primary care and health care sharing ministries. Employers could contribute to these accounts for new hires starting five years after enactment, with a transition rule for existing accounts. The bill would directly affect individuals using these accounts and employers who choose to participate in the new system.
HR 3467 reforms Medicare Advantage (MA) by requiring most plans to use fixed payments per member (capitated payments) starting in 2028, with exceptions for existing plans and special needs plans. It modifies payments by reducing blended benchmarks, changing how health status risk adjustments are calculated (using only face-to-face/telehealth diagnoses), and eliminating quality-based payment increases. The bill mandates automatic enrollment into the lowest-premium MA plan for eligible beneficiaries starting in 2028, with a 3-year enrollment lock-in period unless a hardship event occurs. Additionally, it requires MA plans to include hospice care coverage (with a 2028 transition exception) and adds an exception for durable medical equipment and Part D drugs under the Stark Law.
HR 211, the Equal Access to Contraception for Veterans Act, eliminates out-of-pocket costs for specific contraceptives for veterans using VA healthcare. It amends Section 1722A of Title 38 to prohibit the VA from charging veterans copayments for contraceptive items that must be covered without cost-sharing under federal law (as required by Section 2713(a)(4) of the Public Health Service Act). This means veterans will not pay any amount for contraceptives covered by the federal mandate, such as birth control pills or IUDs, when obtained through the VA system. The bill directly affects veterans enrolled in VA healthcare seeking contraceptive services, ensuring no additional costs beyond what is already mandated for these items.
