Health Plan Weekly

The Supreme Court on June 27 upheld the constitutionality of the Affordable Care Act's preventive care coverage mandate, ensuring that the 15-year-old law survived yet another legal challenge that made it to the highest court in the land.

The ACA’s preventive care coverage mandate requires nearly all health insurers to cover government-recommended preventive services and drugs — such as vaccines, cancer screenings, birth control and pre-exposure prophylaxis (PrEP) for HIV — at no cost to their enrolled members.

Amid mounting consumer, provider and lawmaker frustrations over insurers’ reliance on prior authorizations to control medical costs, a group of payers including major publicly traded companies recently unveiled a pledge to revamp their own PA practices before the federal government takes action. But industry experts say much of what they’re promising is already being mandated in federally sponsored health care programs, and it remains to be seen whether they’ll be ready to adopt these changes on the commercial side, let alone in Medicare or Medicaid.

On June 23, AHIP unveiled a six-pronged plan to improve PA processes across business lines including commercial, Medicare Advantage and managed Medicaid. By Jan. 1, 2026, nearly 50 undersigned organizations intend to: (1) reduce the number of medical procedures subject to PA “as appropriate for the local market each plan serves,” (2) honor existing PAs for in-network services when enrollees change plans as part of a 90-day transition period, and (3) “provide clear, easy-to-understand explanations” of PA decisions, including how to appeal.  

CMS on June 20 finalized a regulation that aims to tighten oversight of the Affordable Care Act exchanges but is also expected to add to the mounting headwinds facing the marketplace by making it tougher for people to get and stay covered.

And while provisions in that regulation won’t go into effect until at least 2026 — and enhanced ACA subsidies will not expire until the end of 2025 — some marketplace insurers are already facing troubles that will only be compounded once the policy environment worsens, one equities analyst recently observed.

Facing higher costs and risk due to provisions in the Inflation Reduction Act (IRA) that went into effect this year, Medicare Part D plans have significantly increased their use of coinsurance and raised deductibles, according to a white paper released on June 19 from the USC Schaeffer Center for Health Policy & Economics.

While a small percentage of people with high drug spending have benefited from the IRA changes, Erin Trish, Ph.D., the study’s lead author and co-director of the USC Schaeffer Center, tells AIS Health that the vast majority of Medicare beneficiaries will see their out-of-pocket (OOP) medication expenses increase as insurers adjust their plan designs. Trish adds that she expected Part D plans to adapt to the IRA, but she adds that she was “surprised by how striking and rapid the change is occurring.”

The Senate parliamentarian has flagged several health care-related provisions in Republicans’ “One Big Beautiful Bill Act” as violating the Byrd Rule. That rule, named after the late Sen. Robert Byrd (D-W. Va.), stipulates that provisions included in a budget reconciliation bill must directly affect federal revenues and spending. Measures that don’t meet those criteria — when reviewed via a process called the “Byrd bath” — can remain in the bill but would be subject to a 60-vote threshold to pass, and Republicans have just a 53-47 majority in the Senate. The provisions flagged by the parliamentarian include those that would change immigrants' eligibility for Medicaid, ban spread pricing in Medicaid managed care contracts with PBMs, and limit states’ ability to use provider taxes to help fund a state's share of Medicaid spending, among others. “Republicans are scrambling to rewrite parts of this bill to continue advancing their families lose, and billionaires win agenda, but Democrats stand ready to fully scrutinize any changes and ensure the Byrd Rule is enforced,” Sen. Jeff Merkley (D-Ore.), ranking member of the Senate Budget Committee, said on June 26.