Insights: Healthcare

End-of-Year Health Care Legislation (ACA, MA, Site Neutral, PBMs, Extenders)

There continue to be indications of interest on the part of Republicans in enacting a bipartisan health care bill by the end of this year. This is being catalyzed by growing focus on the end of year expiration of the ACA enhanced subsidies and the need to address Medicare and Medicaid “extenders”. We anticipate the visibility of this legislative...

Medicare Advantage: Upcoding, Prior Authorization, and Provider Rates

Republican lawmakers are in the early stages of developing healthcare legislation they hope to move through the legislative process on a bipartisan basis by year’s end. The legislation is expected to touch on a variety of issues (i.e., PBMs, various so-called “extenders”) and there is some consideration of including reforms to the Medicare...

Pharmacy Benefit Managers (PBMs)

Though PBM reforms ended up being stripped from Republican’s recently enacted reconciliation bill (the One Big Beautiful Bill Act or OBBBA), lawmaker interest in constraining the practices of industry is not fading. In recent days, Senate Finance Chair Crapo (R-ID) indicated that a bipartisan deal to impose new regulations on PBMs would be a top...

Affordable Care Act (ACA) Subsidies

With the One Big Beautiful Bill Act (OBBBA) having been enacted into law, Republican lawmakers are shifting their focus on the remainder of the legislative agenda for 2025. And in recent days, several Republicans – including some in leadership – have signaled discussions are underway as to whether and how to address the impending expiration of...

Medicare Outpatient/ASC Reimbursement

CMS has issued the CY26 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule. Under the rule, CMS proposes to increase OPPS and ASC payments by an aggregate 2.4% for CY26 relative to CY25 ($b and $480m increases, respectively). That rate update is comprised of 3.2% market basket update reduced by a...

Medicare Physician Fee Schedule (PFS) Reimbursement

CMS has issued the proposed CY26 physician fee schedule (PFS) rule. Under the rule, CMS proposes implementing two separate conversion factors (CFs). For Alternative Payment Model (APM) participants, the aggregate CF is set at $33.59, a 3.83% increase ($1.24) from the CY25 CF of $32.35. For non-qualifying participants (non-QPs), the aggregate...