RISE summarizes recent regulatory-related headlines and reports.
CMS proposes changes to make health plan price data more transparent
The Centers for Medicare & Medicaid Services (CMS) is proposing changes to make payer pricing data more available, easier to locate, and comparable.
The planned changes, made in partnership with the Department of Labor and the Department of the Treasury, build on disclosure requirements issued in the Transparency in Coverage final rules of 2020. Although those rules led to the release of pricing information, the data has been difficult to access and navigate due to oversized files, duplicative data, and information that could not be easily compared across the health insurance landscape.
If finalized, the proposal would address these barriers and simplify how the data is organized, eliminating unnecessary information and making consumer-facing cost tools more accessible to more consumers.
“Every person deserves to know what their health care will cost without needing a team of analysts to decode it,” CMS Administrator Dr. Mehmet Oz said in an announcement. “This overhaul takes a giant step toward that effort. By delivering clearer, more reliable pricing information, we are empowering Americans to take control of their care and creating a more competitive and affordable health system in the process.”
The proposed updates also align plan price comparing tools with consumer protections established under the No Suprises Act. It would require insurers and group health plans to provide the same detailed cost-sharing information whether viewed online, in print, or provided by telephone, upon request. CMS said the updated provisions would ensure that the transparency is not limited by internet access or digital literacy.
The proposed rules do not include major changes to prescription drug disclosure requirements, which the federal departments intend to address separately.
Comments regarding provisions contained in the proposed rule are due by February 21.
HHS seeks info on how to use AI in clinical care, reduce health care costs
The Department of Health and Human Services (HHS) has released a request for information (RFI) for public input on how the department can accelerate the adoption and use of artificial intelligence as part of clinical care. Comments are due by February 23.
HHS is specifically seeking feedback on how it can best use its regulatory, reimbursement, and research and development levers across the government. Among its goals: To accelerate adoption, including how AI can improve patient and caregiver experiences and outcomes, reduce provider burden, improve quality of care, and reduce health care costs.
“Artificial intelligence will be a transformative force for good across America.” said HHS Deputy Secretary Jim O’Neill in the announcement. “We want to hear from you. Our efforts to accelerate AI adoption must be guided by the real needs and experiences of those developing these tools and delivering care.”
Feds extend telemedicine flexibilities for controlled medications
HHS and the Drug Enforcement Administration have once again temporarily extended telemedicine flexibilities to allow physicians to prescribe controlled medications to patients without a prior in-person visit. The flexibilities were first introduced during the COVID-19 public health emergency and have remained in place through temporary extensions. The current extension is the fourth one granted and will run through December 31, 2026.
“Telehealth prescribing flexibilities have become a lifeline for millions of Americans,” said O’Neill. “Extending them ensures continuity of care while we finish the work of putting permanent, commonsense policies in place. This action protects patients, preserves access, and maintains strong controls against diversion.”
HHS said in the announcement that the extension does not change existing requirements that prescriptions be issued for legitimate medical purposes, by licensed practitioners, and in compliance with federal and state law.
Federal judge temporarily blocks Idaho from enforcing actions against UnitedHealth’s MA marketing efforts
U.S. District Court Judge David C. Nye has granted UnitedHealthcare of the Rockies, Inc., and Care Improvement Plus South-Central Insurance Co. a preliminary injunction to stop the Idaho Department of Insurance from enforcing actions against them over limiting access to Medicare Advantage products. The insurer had sued after the state issued a cease and desist order to stop UnitedHealth from discontinued agent commissions in an attempt to discourage consumers from enrolling in Medicare Advantage plans. Nye agreed that UnitedHealthcare would likely succeed in a lawsuit that argues the federal government, which sets rules for Medicare Advantage marketing and broker payments, supersedes state laws.
Nye made a similar ruling in a case against the Idaho Department of Insurance brought by PacificSource Community Health Plans. The Idaho Statesman reports that Nye has extended the temporary restraining order in that case until January 15.
CMS issued a memo in early December to all state insurance departments stating that federal law likely preempts state laws regarding the Medicare Advantage program, including actions related to agent and broker compensation, communication and marketing requirements, and enrollment standards.
CMS establishes rural health transformation office, distributes rural health awards
CMS will establish a new office to implement the $50 billion rural health initiative, a five-year program created under the One Big Beautiful Bill Act to strengthen rural health systems and expand access to care throughout the country.
The agency said the Office of Rural Health Transformation will help guide states in implementing their rural health transformation plans, provide technical assistance, coordinate federal and state partnerships, and ensure strong oversight and accountability throughout the program, which will run through September 30, 2031.
In addition, CMS announced that first year awards for the program will go to all 50 states. This year states will receive awards averaging $200 million within a range of $147 million to $281 million. The funding will help states expand access to care in rural communities, strengthen the rural health workforce, modernize rural facilities and technology, and support innovative models that bring high-quality, dependable care closer to home. CMS said that $10 billion will be available each year from 2026 through 2030.
Health care software company CEO sentenced for $1B fraud conspiracy
An Arizona man was sentenced to 15 years in prison and ordered to pay more than $452 million in restitution for conspiring to defraud Medicare and other federal health care benefit programs of more than $1 billion by operating a platform that generated false doctors’ orders used to support fraudulent claims for various medical items.
Gary Cox, 79, Maricopa County, was the CEO of Power Mobility Doctor Rx, LLC (DMERx), an internet-based platform that generated false and fraudulent doctors’ orders for medical items. According to the Department of Justice, Cox targeted hundreds of thousands of Medicare beneficiaries who provided their personal identifiable information and agreed to accept medically unnecessary orthotic braces, pain creams and other items through misleading mailers, television advertisements, and calls from offshore call centers.
As part of the scheme, Cox connected pharmacies, durable medical equipment (DME) suppliers and marketers with telemedicine companies that would accept illegal kickbacks and bribes in exchange for signed doctors’ orders transmitted using the DMERx platform. Cox received payments for coordinating these illegal kickback transactions and referring the completed doctors’ orders to the DME suppliers, pharmacies, and telemarketers that paid kickbacks and bribes for the orders.
The fraudulent doctors’ orders generated by DMERx falsely represented that a doctor had examined and treated the Medicare beneficiaries when the telemedicine companies actually paid doctors to sign the orders without regard to medical necessity, based only on a brief telephone call with the beneficiary or no interaction with the beneficiary at all. The DME suppliers and pharmacies that paid illegal kickbacks in exchange for these doctors’ orders billed Medicare and other insurers more than $1billion. Medicare and the insurers paid more than $360 million based on these claims.
In June 2025, Cox was convicted of conspiracy to commit health care fraud and wire fraud, three counts of health care fraud, conspiracy to pay and receive health care kickbacks and conspiracy to defraud the United States and make false statements in connection with health care matters.
“This just sentence is the result of one of the largest telemarketing Medicare fraud cases ever tried to verdict,” said Acting Assistant Attorney General Matthew R. Galeotti of the Justice Department’s Criminal Division in an announcement. “Telemedicine scammers who use junk mailers, spam calls, and the internet to target senior citizens steal taxpayer money and harm vulnerable populations. The Criminal Division will continue dedicating substantial resources to the fight against telemedicine and medical equipment frauds that drain our health care benefit programs.”
HHS proposes rule to streamline health IT requirements and advance AI interoperability
HHS, through the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC), has released the Health Data, Technology, and Interoperability: ASTP/ONC Deregulatory Actions to Unleash Prosperity (HTI-5) Proposed Rule.
In an announcement, HHS said that the proposed rule aims to reduce the burden on health IT developers by streamlining the federal voluntary health IT certification program by removing redundant requirements, update information blocking regulations to better promote electronic health information access, exchange, and use so that patients’ access to their data is not blocked; and advance a new foundation of Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces (APIs) that promote AI-enabled interoperability solutions through modernized standards and certification.
The HTI-5 proposed rule is expected to save $1.53 billion in total, including $650 million over the next five years for health IT developers, providers, and other stakeholders.