Health plans would cap some insured patients' drug costs in 2028

Tax credits would follow an income schedule; federal officials would offer a marketplace plan; covered plans would limit some drug costs; and Medicare would cover specified hearing care. The federal plan would cover qualified marketplace customers who, throughout enrollment, are ineligible for Medicare and neither eligible for nor offered job-based coverage. Cost limits cover group and individual health coverage; hearing benefits cover qualifying Medicare patients. Required premium contributions would be 0% of income through 150% of the poverty line, then rise on sliding scales to 2%, 4%, 6%, and 8.5% at 200%, 250%, 300%, and 400%. The rate would remain 8.5% above 400%, with no stated end date. Federal marketplaces would set aside $100 million from insurer user fees in fiscal 2027 and every later fiscal year for enrollment-help grants. Each year's money would remain available until spent. The federal plan would be sold through health insurance marketplaces and could not cost more than comparable options. Officials could require Medicare- and Medicaid-enrolled providers to join beginning in 2028. The section authorizes future funding but does not set aside a specific amount. Starting in 2028, annual prescription-drug cost sharing would be capped at $2,000 for one-person coverage and $4,000 for other coverage, then indexed. Separate overall caps would apply. Premiums, out-of-network balance bills, and uncovered care would not count toward these caps generally under the bill's definition of cost sharing for these limits. Stand-alone dental plans would be excluded from these requirements under this section; separate insulin exceptions are described below as well as under the cost-sharing caps generally under the bill The tax schedule applies to tax years beginning after December 31, 2026. Navigator money starts in fiscal 2027. The federal plan, drug-cost rules, insulin protections, and hearing benefits start in 2028.

Congress would generally repeal the named provisions and cancel listed unused funds; federal and state agencies would apply the Medicaid funding, pharmacy-survey, and drug-payment rules. The repeal covers subtitle B of title VII of Public Law 119–21, except three sections. Medicaid rules cover states and territories, newly eligible patients, pharmacies receiving Medicaid-related payments, and state drug-benefit contractors. Sections 71202, 71306, and 71401 of Public Law 119–21 would remain. Listed unused implementation money and Medicaid money under Social Security Act section 1902(uu)(3) would be canceled. For people newly eligible through Medicaid expansion, each state's federal matching schedule would follow its first three years of coverage, then its fourth, fifth, sixth, and seventh-and-later 12-month periods. It would also apply to covered spending before enactment. During a qualifying quarter, a state's regular federal Medicaid share would rise by 4.8 percentage points for each point its unemployment rate exceeds the lower of its prior 60-quarter 20th-percentile rate plus one point or its prior 12-quarter average plus one point. Current-quarter shares would be capped at 95%. Excess points could raise eligible shares in a four-quarter look-back period, up to 100%. States must avoid tighter eligibility or higher premiums and keep specified enrollees covered at least 12 months unless they leave voluntarily or move. The expansion schedule applies to pre-enactment spending; downturn quarters start on or after January 1, 2026. Retail surveys start at least six months after enactment. Non-retail surveys and covered drug contracts start at least 18 months after.

Federal health officials would use the listed drug-selection counts, apply negotiated prices to participating private plans, and include commercial-market units in Medicare drug-price inflation rebate calculations. The provisions cover drugs eligible for Medicare negotiation, covered commercial-market drug units, and group or individual health plans that do not opt out for a selected drug and price period. Officials would select 30 eligible drugs for negotiated prices in 2030 and 40 in 2031, or every eligible drug if fewer were available. They would select 50 eligible drugs each year starting in 2032. Group and individual plans would be treated as participating for a covered drug and price period unless they affirmatively opted out. Opt-outs would be public. Participating plans would base patient cost sharing on no more than the negotiated maximum price. Part B calculations would count units that Medicare would pay for if furnished to a Part B enrollee. Part D calculations would use manufacturer-reported units, excluding Medicaid units, units already subject to a Part B rebate, and, starting in 2028, units discounted through the 340B program. The listed negotiation counts apply from 2030 onward. Inflation-rebate rules apply to covered quarters or periods beginning after enactment; private-plan participation follows each drug's price period.

Federally regulated job-based plans would process first-choice-drug exceptions, Medicare Advantage plans would report advance approvals, and plans and care providers would follow billing and claim-statement rules. The drug-exception rules cover job-based group plans governed by the federal employee-benefit law known as ERISA and insurance connected with those plans. Other rules cover Medicare Advantage, group and individual coverage, care providers, and facilities. Plans would approve an exception on listed medical grounds, such as when required drugs failed, could cause harm, or would disrupt stable treatment. An approved exception would last at least one year. Within 72 hours of an ordinary request, a plan must decide or ask for only necessary information; after receiving it, the plan has 72 hours to decide. Urgent cases use 24-hour deadlines. Medicare Advantage plans would report approval, denial, appeal, response-time, and technology-use data. The federal health department would publish plan-level results. Plans would use secure electronic requests and enrollee safeguards. An enrollee could qualify for a special enrollment period if a provider left the plan's network and the enrollee was assigned to, currently received care from, or had received care from that provider during the prior three months. Step-therapy starts with the first plan year at least six months after enactment. Medicare Advantage reporting starts in 2028; electronic requests start in 2029. Claim statements start on the first January 1 on or after enactment's first anniversary.

Care sites, health plans, and health-plan service companies would disclose prices, claims, payments, ownership, fees, and contract information. Price posting would cover hospitals, laboratories, imaging centers, outpatient surgery centers, and group and individual health plans. Data-access rules would cover large-employer or large group plans generally tied to at least 50 workers or participants. Care sites would post free website prices in downloadable files, including cash and insurer-negotiated prices, along with ownership details. Senior officials would attest that disclosures were complete and accurate. Updates would be required quarterly when information changed. After notice and correction periods, noncompliant care sites could face daily fines. Hospital caps would vary by bed count and could rise for lengthy or repeated violations; laboratories, imaging providers, and surgery centers would generally face up to $300 per day before later increases. A hospital still out of compliance 90 days after a correction request could not use certain debt-collection actions for bills from services provided while it was noncompliant, even after it later complied. Health plans would give enrollees network prices, estimated cost sharing, deductible progress, and advance-approval rules. A free plain-language web tool could satisfy that duty. Plans would also post downloadable rates, drug prices, out-of-network payment data, and ownership. Price postings start January 1 of the first year beginning on or after enactment's first anniversary. Large-plan data access starts with plan years beginning on or after that anniversary; quarterly reports apply one year after enactment.