Healthcare (Medicare)

This bill (HR 5467, the PAAT Act) requires Medicare Part D plans to cover specific drugs treating autoimmune diseases, hemophilia, and Von Willebrand disease starting in 2027. It directly affects Medicare beneficiaries with these conditions by mandating plan coverage for relevant medications. Key provisions include requiring plans to include all covered drugs for these conditions and prohibiting prior authorization for such drugs more than once per year, unless the drug is short-term, a controlled substance, or has a risk management strategy. The law aims to reduce coverage barriers for these treatments without altering drug approval or pricing.

Radiation Oncology Case Rate Value Based Program Act of 2025 or the ROCR Value Based Program Act This bill establishes a specialized payment program under Medicare for providers and suppliers of radiation oncology services.  Specifically, the Centers for Medicare & Medicaid Services (CMS) must establish a program under which radiation therapy providers (i.e., hospital outpatient departments) and suppliers (i.e., physician group practices and freestanding radiation therapy centers) receive payments for each episode of care provided to individuals with specified types of cancer. An episode of care  means the period beginning on the day radiation therapy planning is furnished to the individual and ending (1) for individuals with bone or brain metastases, 30 days later; and (2) for individuals with other cancer types, 90 days later. Participation in the program is mandatory for providers and suppliers that participate in Medicare, unless the provider or supplier is part of a state-based Center for Medicare & Medicaid Innovation model or qualifies for a significant hardship exemption. The CMS must set payment rates for the program based on national payment rates with specified adjustments (e.g., geographic adjustments). Providers and suppliers who provide certain transportation services for individuals under their care may receive an additional payment. Providers and suppliers must be accredited in accordance with certain standards, subject to payment reductions. The Government Accountability Office must report on (1) implementation of the program, and (2) underserved areas that are in need of more or newer radiation therapy resources.

The Patients Before Middlemen Act (S 882) improves pharmacy access for Medicare beneficiaries by requiring prescription drug plans to allow any pharmacy meeting standard contract terms to join their networks. It establishes "essential retail pharmacies" in medically underserved areas or regions with limited pharmacy access (such as rural areas with no other pharmacies within 10 miles), and creates standards for reasonable and relevant contract terms between drug plans and pharmacies. The bill also increases transparency requirements for pharmacy benefit managers, mandating detailed annual reports on drug costs, rebates, and pricing practices, with many provisions taking effect for plan years beginning January 1, 2028.

HR 772, the Rural ER Access Act, removes a Medicare rule requiring off-campus emergency departments to be within 35 miles of a main hospital campus. Specifically, it directs the Health and Human Services Secretary to revise Medicare regulations (42 CFR §413.65(e)(3)(i)) to eliminate this location requirement. This change directly affects rural hospitals and healthcare organizations seeking to establish or expand off-campus emergency departments. The key mechanism is updating the Medicare eligibility criteria, allowing such facilities to qualify for billing without the previous geographic restriction, potentially increasing access to emergency care in rural areas.

This bill reinstates $200 transfer and manufacturing taxes on most firearms (replacing reduced rates from prior law) and maintains a $5 tax for "other weapons," effective 90 days after enactment. It also adds $1.7 billion to the Medicare Part A trust fund for fiscal year 2026, specifically for hospital insurance. The provisions directly affect firearm sellers/manufacturers through tax changes and Medicare beneficiaries through increased trust fund funding. These are concrete financial adjustments with no new regulatory requirements or eligibility changes. The bill focuses on restoring prior tax rates and providing dedicated Medicare funding, without altering benefit structures.

This bill, S 1168 (Portable Ultrasound Reimbursement Equity Act of 2025), would expand Medicare coverage to include separate reimbursement for portable ultrasound transportation and setup services, mirroring the existing payment structure for portable X-ray services. It directly affects medical equipment suppliers who provide mobile ultrasound services to Medicare beneficiaries. The bill amends Medicare law to require the Secretary to establish payment rules for portable ultrasound services that are substantially similar to those for portable X-ray services under existing regulations. These changes would take effect for services furnished on or after January 1, 2027.

HR 870, the Physicians for Underserved Areas Act, amends Medicare rules to improve how residency slots are redistributed when hospitals close. It requires hospitals to ensure that redistributed residency positions are filled within five years (previously only a vague "likelihood" standard existed). This change directly affects hospitals participating in Medicare that close and the residency programs receiving the reassignable slots. The policy focuses on ensuring residency positions are actually filled after closures, rather than just being available.

HR 5198, the Rural Health Clinic Location Modernization Act of 2025, changes Medicare eligibility rules for rural health clinics by updating the definition of "urban area" used to determine clinic qualification. It replaces the current "urbanized area" standard with a clearer definition: any urban area (per Census Bureau data) having a population of 50,000 or more. This adjustment directly affects clinics seeking Medicare certification, ensuring they meet consistent geographic criteria for rural designation. The change takes effect January 1, 2027, aiming to simplify qualification rules without altering Medicare coverage or benefits.

Territories Health Equity Act of 2025 This bill alters provisions relating to the treatment of U.S. territories under Medicaid, Medicare, and Medicare Advantage. For example, the bill eliminates Medicaid funding limitations for U.S. territories beginning in FY2026, exempts an individual from late-enrollment penalties for Medicare medical services if the individual resided in Puerto Rico as of the date of eligibility and the individual enrolls within five years of such date, and establishes minimum criteria for certain elements used in Medicare Advantage payment calculations for areas within U.S. territories. The bill also allows residents of U.S. territories who are unable to obtain health insurance through their employer or a health insurance exchange to instead obtain coverage that is at least as broad as the coverage available to Members of Congress and their staff through the District of Columbia exchange.

This bill establishes new requirements for pharmacy benefit managers (PBMs) working with Medicare Part D prescription drug plans and Medicaid programs. It mandates that PBMs pay pharmacies a specific reimbursement amount based on drug acquisition costs plus a fixed fee, pass through manufacturer rebates directly to beneficiaries at the point of sale, and prohibits steering practices that direct patients to specific pharmacies. The bill applies to Medicare Part D plans and Medicaid managed care organizations beginning January 1, 2027, affecting how PBMs interact with pharmacies and handle drug rebates. Violations could result in criminal penalties of up to $1 million or 10 years in prison for willful noncompliance. The bill aims to increase transparency and fairness in pharmacy drug pricing for Medicare and Medicaid beneficiaries.