S. 5496: Health for the Commonwealth through Affordability, Reform, and Expansion Act of 2026

This bill would make a broad set of changes to health coverage, prescription drug costs, billing transparency, and Medicaid payments.

Coverage and subsidies

The bill would reverse some recent health law changes, make the Affordable Care Act’s premium tax credits permanent, and expand consumer outreach to help people enroll in coverage. It would also create a new low-cost national health plan.

Prescription drug and out-of-pocket costs

The bill would expand Medicare’s drug price negotiation and inflation rebate rules to apply to more commercial health plans as well, with some plans allowed to opt out if they publicly disclose that choice. It would also create a nationwide out-of-pocket cap beginning in 2028, including a $2,000 annual cap on prescription drug spending under health plans.

For insulin, beginning in 2028, health plans would have to cap cost-sharing at $35 or 25% for a 30-day supply, count that spending toward deductibles and out-of-pocket limits, and cover certain insulin in catastrophic plans. The bill also would lower drug and care costs through other negotiation and pricing rules.

Prior authorization and Medicare Advantage rules

The bill would create a formal process for patients and doctors to seek exceptions to step-therapy requirements, which are rules that require trying one treatment before another. It would also tighten prior-authorization rules for Medicare Advantage plans, including stricter deadlines for decisions and more transparency and reporting requirements.

In addition, people in Medicare Advantage would get special enrollment rights if their provider is terminated from a plan.

Expanded benefits

The bill would expand Medicare coverage for hearing services and hearing aids.

Price transparency and billing disclosures

The bill would require hospitals, labs, imaging providers, ambulatory surgical centers, and health plans to post detailed pricing information publicly in machine-readable form. This includes negotiated rates, ownership information, and other pricing data, and the information would need to be updated regularly and certified as accurate.

It would also require clearer advance explanations of benefits and more detailed itemized bills for patients, along with rules meant to reduce surprise charges. Health plans and providers would face notice, access, auditing, corrective-action, and penalty requirements if they do not comply.

Data sharing and anti-gag rules

Health plans and service providers would have to give plans broad and timely claims, payment, fee, ownership, and pricing data. The bill would ban gag clauses that limit the sharing of certain information, require annual attestations, allow public audits, and impose significant daily penalties for noncompliance.

Medicaid pharmacy payment changes

For Medicaid, the bill would prohibit spread pricing in pharmacy payments and require pass-through pricing instead. This would change how pharmacy benefit managers and Medicaid plans are paid for prescription drugs.

Relevant Companies

• CI - Cigna could be affected by changes to commercial plan drug pricing rules, transparency requirements, and pharmacy benefit management practices.
• UNH - UnitedHealth could be affected through its health insurance and pharmacy benefit operations, especially around prior authorization, drug pricing, and reporting rules.
• HUM - Humana could be affected by Medicare Advantage prior-authorization changes, enrollment rules, and transparency requirements.
• ELV - Elevance Health could be affected by changes to ACA subsidies, commercial plan pricing rules, and drug-cost limits.
• CVS - CVS could be affected through its health plans, pharmacy benefit management business, and Medicaid pharmacy payment rules.
• CI - Cigna could also be affected through Express Scripts and related PBM reforms that change spread pricing and data-sharing obligations.
• CAH - Cardinal Health could be affected indirectly by drug pricing and pharmacy payment changes, depending on its roles in distribution and related services.