S. 4924: Preserving Patient Access Act

This bill would change how some health insurance plans handle provider network changes and prescription drug formulary changes, mainly in Medicare and individual market plans.

Medicare Advantage plans

For Medicare Advantage, the bill would require plans to treat certain doctor or other provider network changes as a reason to protect the enrollee’s access. If a person has had an in-person or telehealth visit with a provider in the last 2 years, and that provider was in-network during the plan’s most recent annual enrollment period, the plan would have to recognize the impact if that provider later becomes out-of-network.

The practical effect is that people would have a clearer basis for changing coverage or addressing access problems when a familiar provider is no longer in-network after they chose the plan.

Prescription drug coverage in Medicare

The bill would also address mid-year negative formulary changes in Medicare drug plans and Medicare Advantage plans that include drug coverage. A formulary is the list of drugs a plan covers. A “negative formulary change” generally means the plan makes a change that is less favorable to the patient, such as removing a drug from coverage or making coverage more restrictive.

If a plan makes one of these unfavorable changes to a drug that the person has used within the prior 6 months, and that drug is still approved for use, the bill would limit how plans can handle that change. The stated goal is to preserve access to drugs that a person was already using and that the plan had been covering.

These Medicare-related changes would apply to plan years starting on or after January 1, 2027.

Individual health insurance plans

The bill would require health insurers selling individual market plans to create a special enrollment period in certain situations. This would let a person switch plans during the year, not just during the normal open enrollment period, if:

• a doctor or other provider they recently saw was in-network under their current plan but later becomes out-of-network; or
• their plan makes a negative formulary change affecting a prescription drug they used recently and that is still approved for use.

The bill also updates the rules for health plans offered through the marketplaces (“Exchanges”) so these new mid-year enrollment rights apply there as well.

Overall effect

In plain terms, the bill is designed to give people more options if their health plan changes its network of doctors or changes coverage for medications after they have already enrolled. It does this by requiring Medicare and individual market plans to provide additional access protections and, in some cases, a chance to switch plans during the year.

Relevant Companies

• HUM — Humana offers Medicare Advantage and Medicare drug plans, so changes to network and formulary rules could affect its plan operations and enrollment management.
• UNH — UnitedHealth, through its UnitedHealthcare business, sells Medicare Advantage and related coverage that could be affected by these network and drug coverage requirements.
• CNC — Centene sells Medicare and individual market health plans in some areas, and the bill could affect how those plans handle provider and drug list changes.
• EW — Elevance Health offers individual market and Medicare plans in certain markets, which could be affected by the new enrollment and coverage rules.
• CVS — CVS Health, through its insurance and pharmacy benefit businesses, could be affected by changes to drug formulary rules and Medicare plan administration.
• CI — Cigna, through its health insurance and pharmacy benefit operations, could be affected where its plans or PBM arrangements interact with formulary change requirements.