RISE summarizes recent regulatory-related headlines and reports.
CMS: Part D demo will cap GLP-1 out-of-pocket costs at $50 per month
The Centers for Medicare & Medicaid Services (CMS) has announced a time-limited Medicare Part D demonstration that would cap participating beneficiaries’ monthly out-of-pocket cost for certain GLP-1 medications at $50 from July 1, 2026, through December 31, 2027. The agency said the Medicare GLP-1 Bridge demonstration will expand predictable access to high-cost, evidence-based obesity treatments while testing a new approach to payment and operations, including centralized claims and pharmacy payment processes. CMS says additional beneficiary guidance will follow ahead of launch. The initiative builds on CMS’ broader efforts to improve access to innovative therapies and support healthier outcomes for Medicare beneficiaries. “These treatments are a major medical advancement, but too many seniors are currently unable to access them due to high cost,” said CMS Administrator Dr. Mehmet Oz in the announcement. “The Medicare GLP-1 Bridge changes that by making these medications more affordable and accessible, while advancing our broader goal of helping Americans live healthier lives.”
House oversight committee flags CPT coding complexity as potential driver of improper payments
House Committee on Oversight and Government Reform Chair James Comer has sent a letter to CMS raising concerns that the Current Procedural Terminology (CPT) code system, which is used as the federal standard for Medicare and Medicaid billing, may be contributing to improper payments and higher health care costs. The letter argues that reliance on a privately maintained coding standard and the complexity of the system may create vulnerabilities for waste, fraud, and abuse, and he requests a staff-level briefing on CMS’ oversight and options to reduce administrative burden or promote alternatives.
HHS launches plan to curb psychiatric overprescribing and expand non-drug care
The Department of Health and Human Services (HHS) has announced a plan to address what it describes as inappropriate psychiatric prescribing, with an emphasis on preventing unnecessary initiation of medications and supporting tapering/discontinuation when clinically indicated. The plan includes near-term education and outreach (SAMHSA reports, fact sheets, webinars), a Technical Expert Panel to inform federal clinical guidance, and program/policy work by CMS to expand access to evidence-based non-medication care and clarify Medicare payment pathways that support deprescribing-related services.
In a letter to providers, HHS encouraged them to prioritize informed consent and shared decision-making, and to regularly review the risks and benefits of psychiatric medications with patients. The letter highlights non-medication approaches, such as family support, psychotherapy, nutrition, and physical activity when clinically appropriate. Providers can also find information in the letter on billing codes that they can use can to support the delivery of evidence-based nonmedication treatments.
Meanwhile, CMS has released guidance for physicians and other practitioners on the importance of deprescribing and related medical care. This guidance clarifies how physicians and other practitioners can be paid for this type of care under Medicare and also directs clinicians to widely recognized resources for deprescribing, including professional society guidelines, peer-reviewed deprescribing protocols, and the U.S. Food and Drug Administration instructions for taper schedules.
Massachusetts AG: $5M settlement and permanent ban over alleged deceptive health plan sales
Massachusetts Attorney General Andrea Joy Campbell announced the state has reached a $5 million settlement with Adroit Health Group, a private health insurance agency based in Texas, over allegations that the company deceptively marketed products as comprehensive health insurance that met federal and state requirements when they did not. Campbell claims that Adroit misled consumers about costs and benefits, charged consumers without authorization, failed to provide refunds to those who attempted to cancel, and did not provide adequate disclosures regarding discount health plans and specified disease insurance policies. The company also used multiple business names, to conduct its operations. The settlement includes restitution for affected consumers and permanently bans Adroit from selling or administering health plans or non-insurance health programs in Massachusetts.