Healthcare (Medicare)

This bill requires Medicare Advantage plans to implement electronic prior authorization systems by 2028 and report detailed transparency data starting in 2027. Plans must publicly disclose approval/denial rates, average processing times (including for appeals), technology use, and other metrics for covered medical services. It mandates 24-hour response standards for expedited requests and routinely approved services, with data collection to analyze access patterns and potential disparities in rural/low-income communities. These changes directly affect Medicare Advantage plans, providers, and seniors enrolled in these plans by standardizing and increasing visibility into prior authorization processes.

S 3593, the "Punishing Health Care Fraudsters Act," increases penalties for healthcare fraud committed against federal programs like Medicare and Medicaid. It raises maximum prison sentences under federal law from 10 to 25 years and 20 to 30 years, and boosts fines from $100,000 to $250,000 per violation. The bill also requires the U.S. Sentencing Commission to update guidelines to better reflect the severity of fraud, considering factors like victim harm, financial loss, and privacy violations. This directly affects individuals or entities committing healthcare fraud, aiming to strengthen deterrence through harsher consequences.

This bill requires the Secretary of Health and Human Services to provide education and outreach about existing Medicare coverage for occupational therapy services. Specifically, it mandates that within one year of enactment, the Secretary must clarify how Medicare covers occupational therapy for mental health and substance use disorder treatment using specific HCPCS codes. The bill directly affects Medicare beneficiaries seeking these services and healthcare providers billing under those codes. It does not change coverage rules but ensures stakeholders understand current policy.

Access to Prescription Digital Therapeutics Act of 2025 This bill provides for Medicare and Medicaid coverage of prescription digital therapeutics (i.e., software applications that are used to prevent, manage, or treat medical conditions). The Centers for Medicare & Medicaid Services must establish a Medicare payment methodology for payments to manufacturers that takes into account certain factors (e.g., ongoing use); manufacturers must report specified information about private payors, subject to civil penalties.

# Summary of the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2026 This comprehensive appropriations bill allocates funding for the fiscal year 2026 to the Department of Labor, Department of Health and Human Services (HHS), Department of Education, and several related agencies. The bill contains numerous specific funding allocations, restrictions, and procedural requirements. Key elements include: 1. **Major Funding Areas**: - HHS receives significant funding for programs including Medicaid, CHIP, Social Security, and public health initiatives - Education receives substantial funding for student financial assistance, career and technical education, and research - Related agencies receive funding for programs like the Corporation for National and Community Service and the Social Security Administration 2. **Key Restrictions**: - Prohibits using funds for abortions except in cases of rape, incest, or to save a woman's life (Section 506-507) - Bans funding for embryonic research or creation of human embryos for research (Section 508) - Prohibits funding for advocacy of drug legalization (Section 509) - Requires transparency in reporting how federal funds are used (Section 505) - Prohibits using funds for propaganda or political activities (Section 503) 3. **Specific Provisions**: - Requires detailed reporting to Congress about fund usage (Sections 516-517) - Mandates notification to Congress before reprogramming funds (Section 514) - Includes numerous rescission provisions that cancel previously appropriated funds - Contains specific requirements for managing federal contracts and grants - Establishes restrictions on using funds for certain types of research or activities 4. **Notable Funding Amounts**: - $24.6 billion for Student Financial Assistance - $49.4 billion for the Supplemental Security Income Program - $14.7 billion for Social Security Administration administrative expenses - $3.2 billion for Higher Education programs - $2.1 billion for Career, Technical, and Adult Education The bill represents a comprehensive funding package with specific constraints on how funds may be used, reflecting ongoing policy debates about government spending priorities in health, education, and social services.

HR 6361, the Ban AI Denials in Medicare Act, prohibits the U.S. Department of Health and Human Services from implementing or testing Medicare models that use artificial intelligence for prior authorization of covered services under traditional Medicare. Specifically, it blocks the existing WISeR model (described in a 2025 federal notice) and prevents future models from using AI to deny coverage for Medicare Part A or Part B services. This bill directly affects Medicare beneficiaries and healthcare providers who would otherwise face AI-driven coverage decisions. The key mechanism is an amendment to the Social Security Act, explicitly banning the use of AI in prior authorization systems within Medicare's innovation models.

The DTC Act of 2025 requires pharmaceutical companies to include a drug's list price (for a 30-day supply) in direct-to-consumer television and digital ads for prescription drugs covered by Medicare or Medicaid. It applies to ads for drugs costing $35 or more per 30-day supply, exempting lower-cost medications. Manufacturers must disclose the list price clearly by July 1, 2026, with penalties of up to $100,000 per violation for noncompliance. The bill aims to provide consumers with upfront pricing information to help them compare costs before filling prescriptions, particularly affecting drugs commonly advertised to Medicare beneficiaries.

This bill prohibits Medicare from paying for orthotics and prosthetics delivered via "drop shipment" (direct shipping to patients without proper training from a qualified provider) starting after its enactment. It expands the list of healthcare professionals who can order these devices to include physical therapists, occupational therapists, orthotists, and prosthetists. The bill also ensures Medicare beneficiaries can get covered replacements for custom-fitted orthotics and custom-fabricated orthotic devices. These changes aim to improve patient safety and access to appropriate care by requiring in-person training and clarifying coverage rules. The Secretary of Health and Human Services must issue implementing regulations within one year of the bill's enactment.

The PEERS Act of 2025 requires Medicare to cover peer support services provided by certified specialists at community mental health centers, rural health clinics, and other specified facilities. It directly affects Medicare beneficiaries with mental health or substance use disorders who receive these services, and providers like community mental health centers that will now bill Medicare for this care. The bill defines peer support services as non-clinical assistance focused on recovery, community integration, and self-empowerment, delivered by individuals certified after recovering from similar conditions. Coverage begins January 1, 2027.

This bill amends the Social Security Act to expand Medicare coverage for clinical social worker services. It removes the current restriction limiting these services to "the diagnosis and treatment of mental illnesses," allowing Medicare to cover a broader range of social worker services in healthcare settings. The change applies to services provided on or after December 1, 2025, directly affecting Medicare beneficiaries who receive social work services for non-mental health conditions. This policy adjustment aims to integrate social workers more fully into general healthcare coverage under Medicare.