legislation & regulation

Trade groups representing health insurers and insurance agents are giving mixed reviews to a recently finalized rule that reinstated strict limits on short-term, limited duration insurance (STLDI) plans.

The rule, first proposed in July 2023, sought to revive Obama administration-era standards regarding STLDI plans — which are exempt from Affordable Care Act consumer protections such as barring insurers from denying coverage to people with preexisting conditions. Both the Obama and Biden administrations were concerned that consumers often mistake such plans for comprehensive coverage, potentially leaving them with nasty surprises when they need care.

A panel of experts will recommend in a formal report to Congress that ground ambulance-related balance bills should be settled using a rate-setting benchmark rather than arbitration, according to one member of the panel; in addition, the report will recommend that Medicare should begin to cover care that is delivered by ambulance personnel but does not result in a hospital transport. The report is under review by CMS, and is expected to kick off another battle on Capitol Hill over surprise billing policy.

Balance or surprise billing generally occurs when a person unwittingly receives care from an out-of-network provider and is then billed by that provider for whatever balance remains after insurance reimbursement. According to a member of the panel, the report will recommend that balance bills for ground ambulance care should be banned in virtually all circumstances, including emergency transports to a hospital, interfacility transports and care delivered by EMTs in the field that does not result in a transport to a hospital.

CMS on April 2 finalized the 2025 Notice of Benefit and Payment Parameters for Affordable Care Act exchange plans. The rule extended the special enrollment period for people with household incomes up to 150% of the federal poverty level to enroll in coverage any month during the year. CMS also attempted to prevent coverage gaps for people switching plans by allowing people to enroll on the first day of the month after they select a plan. In addition, the rule streamlined the process for enrollment on federally facilitated and state-based marketplaces. And beginning in 2027, it will allow states for the first time can add routine adult dental care as an essential health benefit. More than 21 million people enrolled in ACA exchange plans this year.

Prescription drug affordability boards (PDABs) have been rising in popularity as a way for states to tamp down on soaring drug prices. But a recent lawsuit filed by one drugmaker and public remarks from the industry’s main trade group make it clear that the pharma sector sees such boards — and the price caps some are authorized to set — as a major threat.

In a suit filed on March 22, Amgen Inc. takes aim at Colorado’s Prescription Drug Affordability Review Board, which is the closest to becoming the first state board to set an upper payment limit (UPL) on a drug. The state in late February initiated formal rulemaking to set a UPL for Enbrel (etanercept), Amgen’s rheumatoid arthritis treatment, after determining it was unaffordable.

Litigation against health plans over alleged mental health parity violations has proliferated in recent years, with judges notably ruling in favor of UnitedHealth Group and against Elevance Health, Inc. Things may get even more complicated with the Biden administration likely to propose more mental health parity regulation this year, according to attorneys from Manatt, Phelps & Phillips, LLP.

Mental health parity rules, which rely on statutes including the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Consolidated Appropriations Act, 2021, require health plans to cover behavioral health and substance use disorder (SUD) treatment at the same level as medical/surgical benefits.

A new report by Brookings Institution researchers concludes that the No Surprises Act, the 2020 law that banned surprise medical billing, may cause prices — and consequently premiums — to increase, even though policymakers hoped the law would slow or reverse price growth. The report also concludes that a small group of providers, particularly physician staffing groups owned by private equity entities, are responsible for most of the price increases.

This unintended consequence raises the stakes of ongoing litigation between the Texas Medical Association (TMA) and the Biden administration. Those lawsuits challenge regulations governing the NSA-created, HHS-backed arbitration process, called Independent Dispute Resolution (IDR), which resolves balance billing disputes between payers and providers when patients unintentionally receive out-of-network care. The TMA and other provider groups have successfully sued multiple times to block IDR rulemaking that many experts believe would have kept price growth in check.

HHS and the Labor and the Treasury departments on March 28 released final rules pertaining to short-term, limited-duration (STLDI) health plans. Those plans will be limited to last no more than four months, compared to up to three years under the previous rules. The rules will also require issuers of STLDIs “to include a clear, easy-to-understand consumer notice on marketing, application, enrollment, and reenrollment materials, so that consumers can make informed coverage purchasing decisions.” The departments called STLDI plans “junk insurance” and noted they are not subject to consumer protections enacted in the Affordable Care Act, including guaranteeing coverage for people with preexisting conditions.

Jamie Raskin (D-Md.), the ranking member of the House Oversight and Accountability Committee, sent a letter on March 25 to UnitedHealth Group CEO Andrew Witty requesting information about the ongoing cyberattack on Change Healthcare, a UnitedHealth subsidiary. Raskin inquired about details such as what data may have been exposed and what policies UnitedHealth has in place to prevent an attack, and he asked Witty to respond to the 12 questions in writing by April 8. Meanwhile, Reuters reported that UnitedHealth said on March 22 that it would start processing its medical claims backlog of more than $14 billion.

As it marked the 14th anniversary of the Affordable Care Act, the Biden administration in recent days announced several new steps that aim to build on the Medicaid coverage gains achieved by the ACA — and reduce the coverage losses due to Medicaid redeterminations.

On March 27, CMS finalized a rule that aims to streamline eligibility and enrollment processes for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. Among other provisions, the rule prohibits states from conducting coverage eligibility renewals any more frequently than 12 months apart.

One in five state Medicaid programs covered at least one anti-obesity medication in 2023, while the amount of reimbursement for these drugs has increased dramatically over the past decade, according to a recent JAMA study.

The researchers studied state Medicaid coverage policies for six anti-obesity drugs approved by the FDA through 2022 — orlistat, lorcaserin, phentermine-topiramate, bupropion-naltrexone, liraglutide, and semaglutide. For the two GLP-1s — liraglutide and semaglutide — the study examined both their branded versions for obesity treatment (Saxenda and Wegovy) and the versions to treat diabetes (Victoza and Ozempic). (It is likely, per news reports, that a substantial amount of diabetes-coded utilization of GLP-1s is actually off-label weight loss utilization.)

Prescription drug affordability boards (PDABs) have been rising in popularity as a way for states to tamp down on soaring drug prices. But a recent lawsuit filed by one drugmaker and public remarks from the industry’s main trade group make it clear that the pharma sector sees such boards — and the price caps some are authorized to set — as a major threat.

In a suit filed on March 22, Amgen Inc. takes aim at Colorado’s Prescription Drug Affordability Review Board, which is the closest to becoming the first state board to set an upper payment limit (UPL) on a drug. The state in late February initiated formal rulemaking to set a UPL for Enbrel (etanercept), Amgen’s rheumatoid arthritis treatment, after determining it was unaffordable.