Preserving patient access to health care providers and prescription drug coverage under Medicare and individual market plans

(a)

Medicare

(1)

Medicare Advantage plans

Section 1851(e)(4) of the Social Security Act (42 U.S.C. 1395w–21(e)(4)) is amended—(A)in subparagraph (C)(ii), by striking or at the end;(B)by redesignating subparagraph (D) as subparagraph (E); and(C)by inserting after subparagraph (C) the following new subparagraph:

(D)a health care provider with whom the individual has had an in-person or telehealth visit, within the preceding 2 year period, and who was listed as an in-network provider under the plan during the annual, coordinated election period described in paragraph (3) for the plan year becomes an out-of-network provider under the plan.

(2)

Prescription drug plans and MA–PD plans

Section 1860D–1(b)(3) of the Social Security Act (42 U.S.C. 1395w–101(b)(3)) is amended by adding at the end the following new subparagraph:

(F)

Mid-year negative formulary changes

(i)

In general

In the case where a prescription drug plan or MA–PD plan implements a negative formulary change with respect to a covered part D drug dispensed to the part D eligible individual within the previous 6-month period, for which the plan provided coverage, and for which approval or licensure under section 505 of the Federal Food, Drug, and Cosmetic Act or section 351 of the Public Health Service Act is still in effect.(ii)

Negative formulary change

In this subparagraph, the term negative formulary change has the meaning given such term in section 423.100 of title 42, Code of Federal Regulations (or successor regulations).

(3)

Effective date

The amendments made by this subsection shall apply with respect to plan years beginning on or after January 1, 2027.(b)

Individual market plans

(1)

In general

Section 2702(b)(2) of the Public Health Service Act (42 U.S.C. 300gg–1(b)(2)) is amended—(A)by inserting and, as applicable, for mid-plan year changes to provider networks or formularies described in subparagraph (B) before the period at the end;(B)by striking A health and inserting the following:

(A)

In general

A health

; and

(C)by adding at the end the following:

(B)

Special enrollment period for individual market plans

(i)

In general

A health insurance issuer offering individual health insurance coverage shall establish a special enrollment period under which any individual may enroll in the coverage during a plan year if the individual, during the same plan year, is enrolled in other individual health insurance coverage (referred to in this subparagraph as the initial plan) and—(I)a provider with whom the individual had an in-person or telehealth visit within the preceding 2-year period, and who was listed as an in-network provider under the initial plan during the most recent open enrollment period, becomes an out-of-network provider under the initial plan; or(II)the initial plan implements a negative formulary change with respect to a prescription drug dispensed or administered to the individual within the previous 6-month period, for which the initial plan provided benefits, and for which approval or licensure under section 505 of the Federal Food, Drug, and Cosmetic Act or section 351 of this Act is still in effect.(ii)

Negative formulary change

In this subparagraph, the term negative formulary change has the meaning given such term in section 423.100 of title 42, Code of Federal Regulations (or successor regulations), except that, for purposes of this subparagraph, the term a drug covered by the initial plan shall be substituted for the term a covered Part D drug.

(2)

Exchanges

Section 1311(c)(6)(C) of the Patient Protection and Affordable Care Act (42 U.S.C. 18031(c)(6)(C)) is amended by inserting , section 2702(b)(1)(B), after of 1986.