Sponsors (2)
The bill prioritizes continuity of care—protecting access to recently seen providers, recent Part D prescriptions, and telehealth-equivalent visits—while trading off increased insurer/admin costs and potential limits on rapid removal of unsafe drugs.
Medicare Advantage enrollees keep access to a provider who saw them in-person or by telehealth within the prior 2 years, preventing mid‑year loss of an established provider.
People who recently received a Part D prescription (within ~6 months) keep coverage protections if a plan makes a mid‑year negative formulary change, preserving continuity of medication for chronic conditions.
Individuals in the individual insurance market can trigger a special enrollment period if their listed provider becomes out‑of‑network or their drug is removed/changed on a plan's formulary, giving patients a pathway to stay with their provider or medication.
Insurers may face higher costs from limits on mid‑year network and formulary changes, which could lead to higher premiums or fewer plan choices for consumers.
Restricting mid‑year formulary adjustments could hamper plans' ability to remove unsafe, recalled, or clinically inappropriate drugs quickly in some circumstances, potentially endangering patients.
Plans will need administrative and compliance updates by the 2027 effective date, increasing insurer operational costs and administrative burden for healthcare organizations.
Based on analysis of 2 sections of legislative text.
Limits mid‑year MA network removals and Part D formulary changes for recently seen providers and recently dispensed drugs, and creates an individual‑market special enrollment remedy.
Official title: Preserve patient access to health care providers and prescription drug coverage under Medicare and individual market plans.
Introduced June 24, 2026 by Jacklyn Sheryl Rosen · Last progress June 24, 2026
Protects patients from unexpected mid-year network and formulary changes by limiting when Medicare Advantage plans and Part D sponsors may treat an in‑network provider or drug as out‑of‑network or restricted. It also creates a special enrollment period in the individual market when a patient's listed provider becomes out‑of‑network or when a plan implements a negative formulary change that affects drugs dispensed within the prior six months. The bill amends Medicare Advantage, Medicare Part D, the ACA individual‑market parity rule, and Exchange planning‑grant language to add these patient protections and takes effect for plan years beginning on or after January 1, 2027.