Healthcare (Medicare)

HR 4139, the Cutting Copays Act, lowers out-of-pocket prescription drug costs for low-income Medicare Part D beneficiaries. It reduces the maximum copay for generic drugs to $0 starting in 2026 and caps copays for other drugs at $3 before 2026, with future adjustments tied to inflation. The bill directly affects Medicare Part D enrollees who qualify for low-income subsidies, ensuring their annual drug costs stay below set limits. These changes modify existing Medicare Part D cost-sharing rules without creating new programs or altering eligibility.

This bill expands Medicare's drug price negotiation program to cover 50 drugs (up from 20) and requires health insurers to apply negotiated prices to cost-sharing for beneficiaries. It establishes annual out-of-pocket cost-sharing limits for prescription drugs under group health plans and insurance coverage, with specific limits of $2,000 for self-only coverage in 2027 that will increase annually. The bill also sets specific cost-sharing limits for insulin products, requiring coverage with no deductible and cost-sharing of no more than $35 per 30-day supply or 25% of the negotiated price. These provisions affect Medicare beneficiaries, people with group health plans, and health insurers across the country. The bill applies to plan years beginning on or after January 1, 2027.

This bill requires Medicare Advantage plans to implement electronic pre-approval systems for medical services by 2028 and meet transparency reporting standards starting in 2027. Plans must publicly report data on approval/denial rates, appeal outcomes, response times, and technology use for pre-approval requests, including details on how denials relate to clinical criteria. It establishes a 24-hour response timeframe for certain requests and mandates annual reviews of pre-approval requirements based on data and input from seniors and providers. The law directly affects Medicare Advantage plans, seniors enrolled in these plans, and healthcare providers who submit pre-approval requests. These changes aim to make the pre-approval process faster, more transparent, and more accountable for seniors seeking covered medical services.

HR 1349, the Women’s Protection in Telehealth Act, excludes Medicare participation for providers who prescribe, administer, dispense, or furnish abortion-inducing drugs via telehealth unless they meet strict conditions. Specifically, providers must be physicians who physically examine the patient, be present in the same room during drug administration, and schedule an in-person follow-up within 14 days. The bill defines "abortion-inducing drug" as any substance used to terminate a clinically diagnosable pregnancy with knowledge it will likely cause fetal death. This directly affects Medicare-covered telehealth abortion services, requiring in-person care for such treatments rather than remote consultations. The exclusion is permanent for non-compliant providers under Medicare rules.

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.