This legislation, known as the Bipartisan Health Insurance Affordability Act, primarily focuses on extending health insurance affordability provisions, enhancing fraud prevention in health insurance Exchanges, and increasing transparency and accountability for Pharmacy Benefit Managers (PBMs).

It extends the enhanced premium tax credits (PTCs) for two additional years, covering 2026 and 2027. For individuals with household incomes up to 150% of the poverty line, the premium assistance amount is set to exceed $5. For those between 150% and 200% of the poverty line, assistance will decrease linearly, while new premium percentage tables are introduced for incomes exceeding 200%, capping at 9.25% for incomes up to 700% of the poverty line.

To combat fraud, the bill introduces new civil and criminal penalties for agents and brokers who negligently or knowingly provide incorrect or fraudulent information during enrollment in Exchange plans. It mandates a verification process for agent or broker-assisted enrollments in federally-operated Exchanges, requiring documented consent from individuals and ensuring commissions are paid only after any enrollment inconsistencies are resolved.

The legislation also grants the Secretary authority to regulate Field Marketing Organizations (FMOs) and Third-Party Marketing Organizations (TMOs) involved in the enrollment process, requiring them to adhere to marketing standards and report agent/broker terminations. Periodic audits of agents and brokers will be conducted based on complaints or suspected fraud, and a list of suspended or terminated agents and brokers will be shared with relevant entities.

Additionally, the bill requires quarterly checks of the Death Master File to remove deceased individuals from Exchange plans and mandates that Exchanges clearly notify individuals of their premium tax credit amount before enrollment, starting in 2027. The annual open enrollment period for 2026 is also extended to run from November 1, 2025, to March 1, 2026.

For Pharmacy Benefit Managers, the bill imposes new accountability requirements for Medicare Part D plans starting in 2029. PBMs will be restricted to deriving income solely from bona fide service fees, with rebates and discounts required to be fully passed through to Prescription Drug Plan (PDP) sponsors. They must also provide detailed annual reports to PDP sponsors and the Secretary, including comprehensive drug-specific cost data, rebate information, and details on affiliate dispensing and broker compensation.

PDP sponsors will gain audit rights to ensure PBM compliance and accuracy of reported information, with enforcement mechanisms including disgorgement of non-compliant remuneration and anti-retaliation provisions for whistleblowers. Similar transparency and pass-through requirements are extended to ERISA group health plans, mandating PBMs to remit 100% of rebates and other remuneration to the plan or issuer, with provisions for quarterly remittances and audit rights for plan sponsors.

Finally, the bill expands eligibility for Health Savings Accounts (HSAs) to certain qualified Exchange enrollees, specifically those in the lowest-cost bronze plans or plans with lower premiums than previous coverage. It also offers individuals the option to prepay a $5 monthly premium and allows eligible enrollees to direct 50% of their advance premium tax credit into an HSA, up to the annual contribution limits. The Treasury and HHS Secretaries are required to report on the implementation of these HSA provisions and recommend ways to expand HSA accessibility.