黑料不打烊

The听Centers for Medicare & Medicaid Services (CMS)听proposed听听marks a听notable听shift in Marketplace policy,听expanding lower听premium plan options,听relaxing听certain federal standards, and moving more implementation and oversight responsibility to states and Marketplaces.听It also introduces听eligibility and verification policies that could significantly affect听enrollment, operations, and market stability.听

To unpack听what this could mean for plan year 2027 and beyond,听Andrea Maresca听spoke with听Zach Sherman, Managing Director for Coverage Policy and Program Design at听黑料不打烊 (黑料不打烊);听Lina Rashid, Principal at 黑料不打烊;听and听, PhD, Principal at Wakely, an 黑料不打烊 company, who, alongside colleagues, published a听Policy听Brief on state-level and consumer impacts, as well as a Wakely听听on the proposed rule.听

听Q:听When you zoom out from the technical details, what are the big听takeaways听from the proposed 2027 NBPP听for听states, consumers, and听issuers?听

Lina Rashid:听At听a high level, the proposal听reallocates听risk and responsibility across the system. Consumers may see more lower premium options through expanded catastrophic plan eligibility and more flexible bronze plan design, but often with more cost-sharing, higher deductibles, or greater complexity. For consumers, affordability is about more than just premiums; 颈迟鈥檚 about how much healthcare costs for individuals and their families overall and the cost of care when they need it.听

States听are being given options听to听take on more听oversight and operational responsibility听but without additional federal funding.听And issuers are being given听more听flexibility,听but it听comes with听uncertainty听regarding听enrollment听and听risk mix.听

Zach Sherman: The rule鈥檚 cumulative effect matters more than any one policy. Expanded catastrophic eligibility, higher out-of-pocket exposure, relaxed network standards, and tighter verification requirements all interact. Together, they raise questions about access, affordability, and听whether听Marketplaces are听equipped to manage听administrative and enrollment disruption.听

Q: The paper highlights potentially significant enrollment effects. What鈥檚 driving that听dynamic?听

Michael:听Two things stand out. First,听the听proposal implements statutory changes that听remove听advance听premium tax credit (APTC)听eligibility听for certain lawfully present immigrants beginning in 2027. CMS estimates more than a million people could lose eligibility, and听颈迟鈥檚听reasonable to expect most of them听will听exit听the individual market.听

Second, the proposed income verification changes could generate millions of data matching issues (DMIs) that temporarily or permanently cut off access to advance premium tax credits. While CMS projects a relatively modest disenrollment effect, our analysis suggests losses could be meaningfully higher depending on how quickly issues are resolved. We estimate that approximately 4.7 million enrollees could receive DMIs under the proposal, and upward of 80 percent of them could temporarily or permanently lose access to APTCs, putting coverage at risk.听

Zach:听If consumers can鈥檛听afford听the full premiums while resolving a data issue, many will drop coverage. That听creates churn and听administrative strain听that Marketplaces听must听manage.听

Q: How do these policies affect state Marketplaces and regulators specifically?听

Zach:听States are being asked to do more across multiple fronts. Network adequacy oversight is shifting toward states that conduct effective rate review. States may also choose听or feel pressure听to take on Essential Community Provider (ECP) review authority,听including for听new non-network plans.听Accepting that听responsibility听requires legal authority, staff capacity, and technical infrastructure.听

At the same time,听states may need to stand up the State Exchange Improper Payment Measurement (SEIPM) program, which听CMS acknowledges will increase administrative burden.听

The proposed State Exchange Enhanced Direct Enrollment (SBE-EDE) option is also a significant shift. Rather than operating a centralized consumer enrollment platform, Marketplaces would focus on certifying, overseeing, and monitoring multiple third-party entities. As a former director of a state-based Marketplace program, I know this is a fundamentally different operational posture that comes with oversight and compliance costs.听

Q: The proposal also introduces non-network plans. What听should stakeholders be watching here?听

Michael:听听may offer听lower premiums, but they change how access works. Provider participation depends on听the听willingness to accept the plan鈥檚 payment as payment in full.听On paper a plan may meet access standards, but in practice consumers could face difficulty finding care.听That places听additional听oversight听responsibility听on states to听determine听whether access is sufficient in practice.听If aggressively priced听non-network听plans disproportionately attract healthier enrollees,听it听can create financial risk for issuers and for the broader market.听

Q: What does this mean for market stability going forward?听

Zach: Stability will vary by state. States that invest in oversight, consumer assistance, and operational readiness鈥攐ften a state-based Marketplace鈥攎ay be better positioned to manage these changes. Others may see sharper enrollment declines or access issues. That divergence across听states听is an important听signal听from this proposal.听

Q: What should听states听and stakeholders be doing right now?听

Zach:听States should be doing听scenario planning,听assessing听which听flexibilities听to adopt, where to听maintain听higher standards, and whether they have the capacity to take on expanded responsibilities.听These decisions will shape how the rule plays out on the ground.听

Michael:听Issuers should be听, risk听adjustment听exposure, and operational readiness.听All stakeholders should remember听that听comments on the proposed rule are due March 13, 2026.听

Lina:听Notably, CMS听is not done with听regulatory reforms.听The听agency solicited听comment听on听medical听loss听ratio (MLR)听policies听and听paused听Essential Health Benefit听benchmark updates,听as well as issues not covered in this proposed rule, such as revisions to the Section 1332 waiver and听Section听1333 interstate compacts.听States and issuers should be tracking what may come next, not just what鈥檚 in this proposal.

The first quarter of 2026 marked a turning point in federal oversight of pharmacy benefit managers (PBMs), the intermediaries that manage prescription drug benefits for most health plans across the commercial insurance market, Medicare Part D, and other programs. New legislation, agency rulemaking, and enforcement activity collectively signal a new phase of oversight that could materially reshape PBM contracting, compensation, and transparency requirements.听

Most notably,听the following听developments stand out:听

• The听US Department of Labor (DOL)听听new disclosure requirements for PBMs听that听serve听self-insured听Employee Retirement Income Security Act听(ERISA)听plans.听
• The听Consolidated Appropriations Act听of听2026 (CAA 26),听听February 3,听2026,听establishes听comprehensive听PBM听transparency and contracting听requirements听in the听commercial insurance market and Medicare Part D.听
• The听Federal Trade Commission (FTC)听听a settlement听with Express Scripts, Inc.听(ESI),听requiring significant听changes to听ESI鈥檚听business practices.听

Together, these actions signal a trend toward greater PBM accountability, with implications for plans, pharmacies, manufacturers, and听consumers.听This article provides a high-level overview of the听major听recent听developments听in the PBM reform policy landscape, along with key considerations for听stakeholders.听

Medicare Part D: Key Statutory Changes听

Beginning听in听plan year 2028,听CAA 26听makes听significant changes for PBMs operating in Medicare Part听D. Key provisions include:听

• Requiring听PBMs to听provide听annual reports to听plan sponsor clients听detailing aggregate and drug-specific costs听
• Restricting听PBMs compensation听structures, prohibiting payments tied to drug prices, rebates, or price-based benchmarks听and听limiting PBMs to only receive听bona fide service fees that reflect听fair market value听
• Stipulating听additional听parameters related to rebate guarantees, contract terminology, and audit rights听

Additional听provisions听that will take听effect in听beginning with plan year 2029听include:听

• A requirement that听plan听sponsors and PBMs听comply with听forthcoming听standards for 鈥渞easonable and relevant鈥澨齪harmacy听contracting terms and conditions听
• Expansion of听the听enforcement infrastructure听to avert听potential violations of听the program鈥檚听pharmacy contracting听requirements听

Key considerations:听The Centers for Medicare & Medicaid Services (CMS) has broad discretion in implementing these provisions, including setting pharmacy contracting standards, determining which PBM affiliates are subject to new requirements, and defining 鈥渇air market value.鈥� PBMs will face expanded reporting and compliance obligations, while plans and other stakeholders will have opportunities to shape implementation through the regulatory process.听

Commercial Health Insurance Market: Key Statutory Changes听

For the commercial market, CAA 26听establishes听similar transparency听requirements听for PBMs听that听serve听fully insured and self-insured plans, with reporting听required听up to four times per year.听Unlike Medicare Part D, the statute does not prohibit听pricelinked听compensation in the commercial market, but it does require detailed disclosure of PBM fees and revenue streams.听For contracts with听selfinsured听plans, PBMs must remit 100 percent of rebates and fees tied to drug听utilization, subject to specified limitations.听

Key considerations:听These provisions听significantly expand听federal oversight in the commercial market.听PBMs will need to scale compliance infrastructure, while employers and other plan sponsors may听seek听enhanced analytical and actuarial support to interpret disclosures and assess PBM performance.听

Medicaid听Left Out,听For Now.听

Unlike prior听,听CAA 26 does not include Medicaid-specific听PBM听reforms,听such as听 on spread pricing (i.e., a PBM听charges a payer more than the amount it听pays听the dispensing pharmacy for a prescription) and expanded听National Average Drug Acquisition Cost () reporting.听

Key considerations:听These policies听continue to have听听and听could听reemerge in听听legislation.听States,听PBMs,听and managed care plans听should continue听monitoring听for听renewed federal action听on these policies.听

DOL鈥檚 Proposed听PBM Fee Disclosure Rule听

DOL鈥檚 proposed听,听鈥淚mproving Transparency听Into听Pharmacy Benefit Manager Fee Disclosure,鈥澨齱ould require PBMs听serving self-insured ERISA plans to听听information about rebates, manufacturer fees,听pharmacy payments, and spread pricing. In late听February,听DOL听听the public comment period听to听April 15听to allow stakeholders to address how听the听proposed rule听should align with听the newly enacted CAA 26 provisions.听

Key considerations:听DOL听could withdraw the proposal in favor of the statutory framework or could听finalize听the rule to take effect before听the听CAA 26 requirements begin.听Either path would further increase near-term compliance for PBMs and plan听sponsors, and stakeholders should听monitor听this space听closely.听

FTC Settlement with ESI听

The听FTC鈥檚听听with ESI听resolves听insulin-focused听听against the听PBM听and听imposes extensive听requirements related to听transparency, compensation, rebates and fees, and benefit design.听The听settlement also includes听less听common听provisions,听such as a commitment to reshore听and increase disclosures related to听ESI鈥檚听rebate group听purchasing听organization (GPO) functions.听

Key considerations:听If similar听settlements听are reached听with other听PBMs, the听FTC could听play听an expanded role听in shaping PBM market behavior, supplementing legislative and regulatory reforms with enforcement-driven standards.听

State Efforts to Regulate PBMs听

States continue to pursue PBM reforms, with听 of laws enacted in recent years addressing licensure, reporting, pharmacy reimbursement, and contracting standards. Although the Supreme Court鈥檚 2020 听in听Rutledge v. PCMA opened the door to certain state-level reforms, 听have narrowed the scope of permissible state regulation, particularly when听ERISA preemption or Medicare Part D conflicts arise.听

Key considerations:听Stakeholders听operating听across multiple markets听and states will continue to face a complex and evolving听patchwork of requirements,听underscoring the importance of ongoing听policy tracking and compliance听coordination.听

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Recent federal and state actions suggest that PBM reform is entering a more operational phase听defined听by听transparency听and听enforceable standards governing compensation, contracting, and market听behavior. As implementation unfolds, stakeholders across the prescription drug supply chain will need to engage closely with regulators, assess new data flows, and adapt听their听business practices to a more prescriptive oversight environment.听

For more information about the policies described鈥�in this article听and the PBM policy landscape听more broadly,听please contact our experts听听or听Stephen Palmer.听