The following is the latest health policy news from the federal government for June 20-26.  Some of the language used below is taken directly from government documents.

Congress

Senate Majority Leader Thune and House Speaker Johnson continue to press for passage of the “One, Big, Beautiful Bill” by July 4, the deadline set by President Trump.  Leader Thune had hoped to bring the bill to the Senate floor early this week but continued disagreements over cuts to Medicaid have slowed progress.  Earlier this week, in an attempt to assuage senators’ concerns that the bill’s Medicaid cuts would imperil rural hospitals, Senate leaders proposed a rural health care fund that would make grants available to all types of rural health care providers.  While some senators support the idea of a rural fund, the proposal has not persuaded enough senators to support the bill’s cuts to provider taxes.

Further slowing progress, the Senate parliamentarian today ruled that a number of health care provisions in the Senate’s bill, including changes to Medicaid provider taxes, do not meet the rules of reconciliation; Senator Thune quickly stated that the Senate would not overrule the parliamentarian’s decisions, so the Finance Committee will have to re-work these sections.

The health care aspects of the bill that the parliamentarian flagged as inappropriate for inclusion in reconciliation legislation are:

  • provider taxes
  • gender transition care
  • Medicaid eligibility for immigrants
  • Medicare coverage for immigrants
  • Affordable Care Act tax credits for immigrants
  • the elimination of a Medicaid grace period for immigrants
  • Affordable Care Act tax credits for immigrants ineligible for Medicaid
  • pharmacy spread pricing
  • reduced federal Medicaid funding for certain states
  • Affordable Care Act cost-sharing reductions
  • abortion restrictions for cost-sharing reduction payments

Senator Jeff Merkley (D-OR), the Democratic ranking member of the Senate Budget Committee, has been posting updates on the parliamentarian’s rulings.  Find links to lists of provisions that have been ruled violations and future updates here.

Despite this apparent setback, Leader Thune has stated that a Friday vote in the Senate is still possible.  If the bill passes the Senate, House Republicans will be expected to unite and pass the Senate’s bill without changes.

While the Senate continued its deliberations this week, the Congressional Budget Office weighed in with its analysis of the Medicaid components of the version of the reconciliation bill already passed by the House, concluding that enacting those provisions would increase the number of people without health insurance by 7.8 million in 2034 relative to baseline projections under current law; see its report here.

Centers for Medicare & Medicaid Services
  • CMS has finalized a regulation that addresses marketplace integrity and affordability under the Affordable Care Act.  According to the agency, the rule will reduce individual health insurance premiums by approximately five percent on average.  Among other things, the final rule:
    • Repeals the monthly special enrollment period (SEP) for individuals with projected household incomes at or below 150 percent of the federal poverty level.
    • Requires income verification to ensure that people qualify for premium subsidies.
    • Requires eligibility verification for the majority of enrollments through SEPs.
    • Reduces advance payments of the premium tax credit (APTC) by $5 a month for individuals who are auto-re-enrolled in fully-subsidized plans without eligibility verification.
    • Standardizes the annual open enrollment period starting with the 2027 plan year so that it ends by December 31 for all health insurance exchanges.
    • Prohibits federal subsidies to help cover the cost of specified sex-trait modification procedures.
    • Reinstates HHS’s previous 2012 interpretation of “lawfully present” to exclude Deferred Action for Childhood Arrivals (DACA) recipients from eligibility and enrollment in ACA exchange coverage and Basic Health Program coverage in states that elect to operate a Basic Health Program, including advance payment of tax credits, premium tax credits, and cost-sharing reductions.
    • Repeals a rule that prohibits issuers from denying health insurance coverage based on unpaid past-due premiums.
    • Eliminates the automatic 60-day extension of the statutorily-required 90-day period for resolving income inconsistencies.
    • Eliminates the requirement that exchanges accept an applicant’s or enrollee’s self-attestation of projected annual household income when the exchange attempts to verify the attested projected annual household income with the IRS but the IRS confirms there is no such tax return data available.

Learn more about the final rule from this CMS news release; a CMS fact sheet; and the final rule itself.

  • CMS has posted a bulletin with the quarterly update of its durable medical equipment, prosthetics, orthotics, and supplied (DMEPOS) fee schedule.  Find the bulletin here.  It takes effect on July 1.
  • CMS has posted a bulletin presenting a national coverage determination for implantable pulmonary artery pressure sensors for heart failure management.  Find the bulletin here.
  • CMS has issued a notice explaining that it will exercise enforcement discretion on personnel requirements under the Clinical Laboratory Improvement Amendment (CLIA) until it has an opportunity to address those requirements in future rulemaking.  Learn more about the specific current requirements that CMS will not enforce from this announcement.
  • CMS has added the following items to its Quality Payment Program resource library.  All of these links are direct downloads of zip files.
Department of Health and Human Services
  • After a meeting with representatives of the health insurers Aetna, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Inc., Kaiser Permanente, and UnitedHealthcare, along with AHIP, the health insurance industry’s national trade association, HHS announced that the companies had pledged “… to streamline and improve the prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace® and commercial plans….”  Specifically, HHS announced that the insurers had agreed to:
    • Standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces.
    • Reduce the volume of medical services subject to prior authorization by January 1, 2026.
    • Honor existing authorizations during insurance transitions to ensure continuity of care.
    • Enhance transparency and communication around authorization decisions and appeals.
    • Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027.
    • Ensure that medical professionals review all clinical denials.

Learn more about the meeting and its outcome from this HHS news release.

  • In a recent review, HHS’s Office of the Inspector General (OIG) found that Medicare Part D plans generally include the drugs most commonly used by dually eligible Medicare and Medicaid enrollees.  Learn more from this OIG report.
  • The OIG has issued an unfavorable opinion regarding a medical device company’s proposal to pay the costs its customers otherwise would incur for a third-party company to screen and monitor the requestor for exclusion from federal health care programs and to ensure compliance with certain other legal requirements.  Learn more from this OIG advisory opinion.
  • HHS’s Health Resources and Services Administration (HRSA) has issued updated award terms requiring HRSA-funded health centers to provide insulin and injectable epinephrine to low-income patients at or below the price paid by the center through the 340B drug pricing program.  HHS believes the new award terms will reduce prices and improve access to insulin and injectable epinephrine.  Learn more from this HHS news release.
  • HHS’s Administration for Strategic Preparedness and Response (ASPR) and more than 50 partner organizations launched the first of several complex patient movement activities as part of the “Tranquil Passport” exercise.  This four-day, full-scale exercise seeks to test and validate the nation’s ability to transport simulated patients with high-consequence infectious diseases safely and securely to regional treatment centers and to test the capabilities of a new portable biocontainment unit.   Lessons learned are expected to inform future exercises and real-world responses.  Learn more from this HHS news release.
Approved Medicaid State Plan Amendments

CMS has approved the following state plan amendments for Medicaid and CHIP programs.

  • To New Hampshire, providing for targeted case management service coverage for Medicaid recipients with substance use disorder and to align with CMS Medically Unlikely Edit coding, effective on January 1, 2025.
  • To Texas, updating the physician and other licensed practitioners’ services fee schedules, effective March 1, 2025.
  • To California, eliminating the “four walls” limitation for Indian Health Services-Memorandum of Agreement providers and making a technical change to the title of psychological assistant to psychological associate to align with recent state law changes.
  • To Utah, adding an exception to the four walls requirement for clinic services provided by Indian Health Service or Tribal facilities for clinics located in rural areas and for clinic services delivered to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address.
  • To Louisiana, making provisions governing Indian Health Services to implement a mandatory exception to the Medicaid clinic services four walls requirement for Indian Health Services and Tribal clinics.
  • To Alaska, complying with the mandatory exception to the Medicaid clinic services benefit four walls requirement for Indian Health Services and Tribal clinics.
  • To Nevada, adding an exception to the four walls requirement for clinic services provided by Indian Health Service or Tribal facilities.
  • To Tennessee, updating Attachments 3.1-A and 3.1-B of the Medicaid state plan to comply with CMS’s final rule amending 42 CFR 440.90.
  • To Kentucky, permitting Kentucky to enter into value-based supplemental rebate agreements with drug manufacturers on a voluntary basis.
  • To Rhode Island, implementing a legislative mandate to establish an additional disproportionate share hospital (Medicaid DSH) pool of $12.9 million designated specifically for payments to government-owned and operated providers.
  • To Arizona, authorizing the Arizona disproportionate share hospital (Medicaid DSH) pool 1, 2, 1A, 2A, and 4 payments for the DSH state plan rate year ending 2025.
  • To Massachusetts, increasing nurse midwives’ allowable fees to 100 percent of the allowable listed fees in the physician pricing regulations.
  • To Illinois, adding non-licensed certified professional midwives to provide maternity services under the category of preventive services.
  • To New York, adding multidimensional family therapy services under the rehabilitative services benefit.
  • To Wisconsin, updating reimbursement rates for LARC/ventilator/brain injury care inpatient payments that are paid outside the DRG.
HHS Newsletters, Reports, and Videos
Government Accountability Office (GAO)
  • The GAO has reviewed the effectiveness of Medicaid managed care plans in ensuring that children enrolled in those programs receive the comprehensive set of screening, diagnostic, and treatment (EPSDT) services to which they are entitled.  Learn more about its findings and recommendations for addressing the shortcomings it found in the report “Medicaid Managed Care:  Actions to Improve the Extent to Which Children Receive Medical Screenings and Treatment.”
  • While Medicaid managed care’s improper payment estimate has been at or near zero percent, the GAO and others have identified risks that are not accounted for in such estimates, including payments from managed care plans to providers for services that were not delivered.  The GAO examines this issue and offers recommendations for addressing the potential problems it found in its report “Medicaid Managed Care:  Improper Payment Estimate.”
  • The GAO has published a report on Medicaid and CHIP disenrollments after COVID-19, including its findings that those disenrollments varied across states and populations.  Find that report here.
Stakeholder Events

CMS – CMS Quality Conference – July 1-2

CMS will hold a quality conference on Tuesday, July 1 and Wednesday, July 2.  Go here for the conference agenda, an FAQ, and to register to participate; participation in the conference in person, in Baltimore, is now closed but individuals may still participate virtually.

CMS – Agency for Healthcare Research and Quality – Understanding the CMS Patient Safety Structural Measure Requirements for Hospitals – July 8

CMS’s Agency for Healthcare Research and Quality will hold a webcast on Tuesday, July 8 at noon (eastern) to provide an overview of CMS’s patient safety structural measure and how the AHRQ Surveys on Patient Safety Culture® (SOPS®) hospital survey, and a shorter SOPS pulse survey version, can be used to meet requirements for Domain 3:  Culture of Safety & Learning Health Systems.  Go here to learn more about the webcast and to register to participate.

HHS – Agency for Healthcare Research and Quality – July 17

HHS’s Agency for Healthcare Research and Quality (AHRQ) will host a webinar on July 17 at 12:30 p.m. (eastern) that covers how empowering patients to take an active role in their health is key to driving meaningful and sustainable behavior change through tools such as clinical decision support systems, artificial intelligence (AI)-powered platforms, and mobile health apps.  Go here to learn more about the webinar and to register to participate.