Congress
ACA Subsidies – The House is expected to vote to approve a three year extension of enhanced premium tax credits for the ACA Exchanges this week. However, this is not expected to gain traction in the Senate. Instead, a group of Senators are working on a two-year modified ePTC extension. The group is expected to release details next week those details ARE likely to include an income cap, required minimum premium payments, and ways for consumers to get HSAs instead of premium subsidies.
Shutdown – Several news outlets reported that progress was being made on budget bills that would avoid another government shutdown. Congress has until the end of January to fund the government.
Reconciliation Round #2? House Republicans are considering whether to attempt another reconciliation bill this spring. Politico reported that if such a bill was pursued it would focus on affordability issues such as making homeownership easier or increasing non-ACA coverage options.
CMMI
CMMI announced a slew of CMMI models at the end of the year. Three of the models focused on drug costs (GUARD – Part D drugs, GLOBE – Part B Drugs and BALANCE – GLP1s. The most pressing is the BALANCE model, which is a voluntary model where CMS will negotiate drug pricing for manufacturers of GLP-1 medications starting in 2027. Part D plan sponsors have until Friday, January 8, to submit a non-binding notice of intent to participate.
Rural Health Fund
CMS announced amounts for the rural health fund. The amounts ranged from Texas’ $281 million to New Jersey’s $147 million. The funds are supposed to begin flowing in October 2026 and continue over the next five years. CMS intends to monitor implementation and potentially rescind announced amounts.
Medicare Advantage Regs
Modern healthcare ($) reported that CMS is considering requiring insurance companies that sell MA chronic special needs plans (C-SNPs) to also be Medicaid managed care contractors. This would limit the types of insurers that could offer C-SNPs and may benefit insurance companies that are already heavily involved in the Medicaid program. The first opportunity CMS may have to regulate on this is via the Advance Notice, which is currently being reviewed by OMB.
Flu Season
Flu cases, hospitalizations, and deaths continue to climb. The CDC estimates that 8.2% of outpatient doctor’s visits were for flu-like symptoms, the highest since 1997.
Child Vaccine Schedule
Secretary Kennedy, on January 5th, issued changes to the federal childhood vaccination schedule. The changes dramatically reduced the number of recommended vaccines for children. Previously in December, HHS also made changes the vaccine schedule. KFF has a good tracker summary of how these changes impact insurance coverage requirements here.
