Bipartisan Health Care Act
- Sponsor
- Sen. Wyden, Ron [D-OR]
- Committees
- Finance Committee (primary)
- Last action
- Mar 6, 2025
Bottom line
The Bipartisan Health Care Act aims to stabilize and modernize the U.S. health care system through broad extensions of existing programs and targeted reforms to drug pricing and service delivery.
What it actually does
This bill is a comprehensive legislative package designed to extend numerous expiring health care programs, introduce new policies to improve health care delivery and access, and reauthorize key public health initiatives. It addresses areas such as Medicaid, Medicare, public health preparedness, substance use disorder treatment, and Food and Drug Administration authorities, with a notable focus on drug pricing transparency and accountability for pharmacy benefit managers.
Proponents argue
Supporters argue that this bill is crucial for preventing disruptions in critical health care services by extending vital programs like community health centers, the National Health Service Corps, and various Medicare payment adjustments. They contend that the provisions on PBM oversight and drug pricing transparency will lower costs for consumers and plans, while expanded telehealth and home-based care options will improve access and modernize delivery, particularly for vulnerable populations and those in rural areas.
Opponents contend
Critics may argue that while some extensions are necessary, the bill's broad scope and new mandates could lead to increased federal spending or administrative burdens for states and health care providers. Concerns might be raised about the specific mechanisms for drug pricing reform, potential unintended consequences for the pharmaceutical supply chain, or the inclusion of certain policy riders that may not have undergone sufficient standalone scrutiny.
This is a very long and detailed omnibus bill, requiring significant time for a thorough review. The time given for public review is currently ample as it is in the early stages of the legislative process.
Title I, Sec. 101
Streamlined Enrollment for Out-of-State Medicaid/CHIP Providers
This provision requires states to adopt a streamlined enrollment process for out-of-state providers in Medicaid and CHIP programs. This allows eligible providers, particularly those already screened by Medicare or another state's Medicaid program, to enroll more easily to serve individuals under 21, reducing administrative barriers and ensuring a 5-year enrollment period unless terminated.
Supporters argue
Proponents argue that this streamlines access to care for children, especially those with complex needs, by making it easier for qualified providers to serve them across state lines. It reduces duplicative administrative work for providers and states, fostering a more efficient healthcare system.
Critics contend
No specific opposition is typically raised against this provision, as it aims to reduce administrative burden and improve access. However, some might express concerns about potential challenges in monitoring and oversight of out-of-state providers, or the need for robust fraud prevention measures.
Tradeoffs
The provision balances the desire for increased access to care and reduced administrative burden with the need to maintain program integrity and oversight of providers, particularly across state lines.
Title I, Sec. 102
Adjustments to Home and Community-Based Services (HCBS) Coverage and Demonstration Program
This section increases transparency for Medicaid HCBS waivers by requiring states to report annually on waiting lists, screening processes, and service delivery times. It also establishes a demonstration program allowing up to five states to expand HCBS coverage to individuals who do not meet institutional level-of-care criteria but have needs-based criteria, with planning grants and specific reporting requirements.
Title I, Sec. 113
Preventing Abusive Spread Pricing in Medicaid
This section mandates a transparent prescription drug pass-through pricing model for Medicaid contracts with Pharmacy Benefit Managers (PBMs) or managed care entities. It requires that payments for drugs and administrative services are clearly defined, with ingredient costs and professional dispensing fees passed through entirely to pharmacies. Any spread pricing (where the PBM charges the plan more than it pays the pharmacy) is disallowed for federal matching payments, and PBMs must provide detailed cost and payment information to states and the Secretary.
Title II, Sec. 209
Extension of Certain Telehealth Flexibilities in Medicare
This section extends several key Medicare telehealth flexibilities, originally expanded during the COVID-19 public health emergency, through December 31, 2026. These include removing geographic requirements and expanding originating sites, expanding eligible practitioners, extending telehealth services for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), delaying in-person requirements for mental health services, and allowing audio-only telehealth services. It also requires modifiers for certain telehealth claims.
Title II, Sec. 222
Adjustments to Medicare Part D Cost-Sharing Reductions for Low-Income Individuals
This section modifies Medicare Part D cost-sharing for low-income individuals. For plan year 2027 and subsequent years, it sets the copayment for generic drugs at $0. For preferred multiple source drugs, the copayment will be the prior year's amount adjusted by the consumer price index, or less, if applicable. For other drugs, a similar inflation-adjusted copayment will apply. These amounts are subject to rounding rules.
Title II, Sec. 223
Requiring Enhanced and Accurate Lists of (REAL) Health Providers Act (Provider Directory Accuracy)
This section requires Medicare Advantage (MA) organizations to maintain accurate, publicly available provider directories for network-based plans, starting in 2027. Directories must be verified at least every 90 days (or annually for facilities) and updated within 5 business days if a provider leaves the network. If information cannot be verified, it must be indicated. Enrollees who rely on an inaccurate directory for out-of-network services will only pay in-network cost-sharing. MA organizations must also annually analyze and report on their directory accuracy scores, which will be publicly posted.
Title II, Sec. 224
Medicare Coverage of Multi-Cancer Early Detection Screening Tests
This section establishes Medicare coverage for multi-cancer early detection (MCED) screening tests starting January 1, 2029. These tests must be FDA-cleared or approved, be genomic sequencing blood or blood product tests (or comparable), and determined by the Secretary to be reasonable and necessary for prevention/early detection. Coverage is limited to individuals aged 50-65 (with a gradual increase in the upper age limit) and only once every 11 months. These limitations do not apply if the test receives an A or B rating from the USPSTF.
Title II, Sec. 227
Modernizing and Ensuring PBM Accountability in Medicare Part D
This section imposes new requirements on Pharmacy Benefit Managers (PBMs) and their affiliates in Medicare Part D, effective 2028. PBMs can only derive income from bona fide service fees, with specific rules for incentive payments and full pass-through of manufacturer rebates/discounts to PDP sponsors. PBMs must provide extensive annual reports to PDP sponsors and the Secretary, detailing drug spending, remuneration, and formulary decisions, especially regarding generic and biosimilar drugs and affiliated pharmacies. PDP sponsors gain audit rights and PBMs are held accountable for violations.
Title IV, Sec. 401
Extension of Funding for Community Health Centers, National Health Service Corps, and Teaching Health Centers
This section extends crucial funding for several public health programs. Community Health Centers receive $2.315 billion for April-September 2025 and $4.6 billion for FY2026. The National Health Service Corps receives $176.7 million for April-September 2025 and $350 million for FY2026. Teaching Health Centers that operate Graduate Medical Education programs receive $112.8 million for January-September 2025, and then increasing amounts from $225 million in FY2026 to $300 million in FY2029.
Title V, Sec. 501
SUPPORT for Patients and Communities Reauthorization Act of 2025
This section provides the short title for Title V, reauthorizing the SUPPORT for Patients and Communities Act. This reauthorization continues and updates numerous programs aimed at addressing the opioid crisis and substance use disorders, covering prevention, treatment, and recovery services.
Title VI, Sec. 601
Pandemic and All-Hazards Preparedness and Response Act (PAHPA)
This section provides the short title for Title VI, reauthorizing and updating the Pandemic and All-Hazards Preparedness Act (PAHPA). This reauthorization continues and enhances federal, state, and local readiness and response capabilities for public health emergencies and all-hazards threats, including provisions related to medical countermeasures, diagnostic tests, and infrastructure.
Title VII, Sec. 708
SCREENS for Cancer (National Breast and Cervical Cancer Early Detection Program)
This section reauthorizes and updates the National Breast and Cervical Cancer Early Detection Program. It expands the program's focus from detection and control to prevention, detection, and control of breast and cervical cancer. It also enhances support activities to increase screenings, such as navigation services, and aims to reduce disparities in incidence, morbidity, and mortality. Funding is reauthorized at $235.5 million annually for fiscal years 2025 through 2029.
Title VIII, Sec. 805
Limitations on Exclusive Approval or Licensure of Orphan Drugs
This section amends the Federal Food, Drug, and Cosmetic Act to limit orphan drug exclusivity. Instead of applying to the 'same disease or condition,' exclusivity will now apply only to the 'same approved use or indication within such rare disease or condition.' This means if a drug is approved for a specific use within a rare disease, another drug for a different use within the same rare disease could still gain approval and market exclusivity. This applies to all designated orphan drugs, regardless of their designation or approval date.
Title IX, Sec. 901
Oversight of Pharmacy Benefit Management Services (Commercial Market)
This section mandates increased transparency and oversight for Pharmacy Benefit Managers (PBMs) in the commercial health insurance market (group health plans and health insurance issuers), effective 30 months after enactment. PBMs and their applicable entities cannot limit disclosure of information to plans. PBMs must submit semi-annual reports to group health plans detailing drug costs, compensation, rebates, and formulary decisions, with specific requirements for large plans and affiliated pharmacies. Plans must provide summary documents to participants upon request. The Secretary of HHS will enforce these requirements with civil monetary penalties for violations or false information.
Title IX, Sec. 902
Full Rebate Pass-Through to Plan; Exception for Innocent Plan Fiduciaries (ERISA)
This section amends ERISA to require that, for pharmacy benefit management services under group health plans, PBMs must remit 100% of rebates, fees, alternative discounts, and other remuneration received from applicable entities back to the group health plan or health insurance issuer. This applies to contracts entered into or renewed 30 months after enactment. It also provides an exception for 'innocent plan fiduciaries' who reasonably believed PBMs were remitting required amounts and take corrective action upon discovery of non-compliance. Rebates must be remitted quarterly and fully disclosed.
Title IX, Sec. 904
Title 35 Amendments (Patent Infringement for Biological Products)
This section amends Title 35 of the U.S. Code, which governs patents, to expand the scope of patent infringement actions for biological products. It clarifies that for biosimilar applications, infringement extends to any patent claiming the biological product, its use, or manufacturing method. Crucially, it limits the number of patents a reference product sponsor can assert in an infringement action against a biosimilar applicant to a total of 20, with no more than 10 issued after 4 years post-reference product approval. This limit can be increased by a court for good cause.
Requires states to regularly review the Death Master File (DMF) at least quarterly to identify deceased Medicaid enrollees and promptly disenroll them, discontinuing payments. If an error occurs, the individual must be immediately re-enrolled retroactively.
Sec. 107, Title I (Medicaid)
Why it matters:This is standard legislative practice for administrative updates to existing programs. While important for program integrity, it's not a headline policy change and is placed within technical amendments to the Medicaid statute.
Case for: Proponents argue this is a crucial program integrity measure that prevents fraudulent payments for deceased individuals, saving taxpayer dollars and ensuring accurate enrollment records. The retroactive re-enrollment provision protects individuals from erroneous disenrollment.
Case against: No specific opposition is typically raised against preventing payments to deceased individuals. However, some might express concerns about the administrative burden on states for frequent data matching and the potential for errors in the DMF leading to wrongful disenrollment, though the re-enrollment clause mitigates this.
Estimated impact: Potentially millions of dollars in prevented improper payments annually across states, plus administrative costs for states to implement the new data matching and disenrollment processes.
Amends the Balanced Budget and Emergency Deficit Control Act of 1985 to modify Medicare sequestration. It specifies that for the first two months of FY2033, the payment reduction will be 2.0 percent, but for the last 10 months of FY2033, the payment reduction will be 0 percent.
Sec. 229, Title II (Medicare)
Why it matters:This is a classic example of a budget maneuver, often used to adjust future spending projections without impacting current fiscal years. The delayed effective date and technical nature make it less visible to the public and potentially less scrutinized in the immediate legislative cycle.
Case for: Proponents might argue this is a necessary future adjustment to Medicare spending, potentially as part of a broader budget negotiation, or to provide relief to providers in a future fiscal year without impacting near-term budget targets.
Case against: Critics would argue that delaying the impact of sequestration or eliminating it for most of a future fiscal year could contribute to long-term federal debt. They might also contend that such a distant change lacks transparency and accountability, as it's far removed from current political cycles.
Estimated impact: Potentially billions of dollars in reduced Medicare payment reductions in FY2033, shifting costs or reducing savings that would otherwise occur under current law.
Prohibits the Secretary of Health and Human Services from funding research that may involve the creation, transfer, and use of enhanced pathogens of pandemic potential or listed biological agents/toxins if such research is conducted by a foreign entity at a facility in a 'country of concern.' Countries of concern initially include China, North Korea, Russia, and Iran, with the Director of National Intelligence able to add others based on malicious intent and reporting to Congress. This limitation expires December 31, 2026, and can be waived by the President during an initial outbreak response.
Sec. 629A, Title VI (PAHPA)
Why it matters:This provision addresses sensitive national security and biosecurity concerns, which are often handled with specific, technically worded legislative language. Its placement in a broader public health preparedness bill allows it to be enacted as part of a larger, must-pass package, potentially avoiding standalone debate on its specific foreign policy implications.
Case for: Proponents argue this is a critical national security measure to prevent adversarial nations from conducting dangerous research with U.S. funding that could lead to bioweapons or accidental pandemic-causing pathogen releases. They contend it protects U.S. interests and reduces global biosecurity risks.
Case against: Critics might argue that blanket prohibitions on research collaboration could hinder scientific progress, especially in areas requiring international cooperation to understand and combat global health threats. They may also raise concerns about the broad definition of 'country of concern' and the potential for political rather than purely scientific motivations in adding countries to the list.
Estimated impact: Potentially millions of dollars in redirected or unfunded research, impacting international scientific collaborations and U.S. foreign policy in biosecurity. The impact on specific research outcomes is difficult to quantify but could affect global pathogen surveillance and countermeasure development.