CSRO Priorities included in GOP Reconciliation Bill | | |
The U.S. House of Representatives passed the GOP’s budget reconciliation package just before the Memorial Day holiday. The legislation narrowly passed the House in a 215-214 vote early Thursday morning after an all-night debate. CSRO priorities within the package include:
-
Medicare Physician Fee Schedule (PFS): The provision would replace the differential payment updates under MACRA (currently 0.25% for those participating in MIPS and 0.75% for qualifying participants in an Advanced APM) with a single PFS payment update based on the Medicare Economic Index (MEI). Through this provision, the PFS would be updated based on 75% of MEI in 2026. In 2027 and each subsequent year, physicians would receive 10% of MEI. The legislation does not address the 2.83% Medicare physician cut that went into effect on January 1. The incentives and penalties associated with QPP participation remain in place, as are budget neutrality requirements.
-
PBM Reform: The package included Medicare Part D delinking, one of CSRO’s core PBM reform policies. Delinking would require PBMs to charge a flat fee instead of a rate based on the drug list price beginning in 2028. All rebates, discounts, and concessions must be fully passed through to the plan sponsor. Greater PBM transparency and reporting to the health plan are also required under this section. While not a CSRO priority, the package also bans spread pricing in Medicaid 18 months after enactment. Spread pricing occurs when the PBM charges the health plan more than they pay the pharmacy for the medication, and then the PBM keeps the “spread” as profit. The U.S. Government Accountability Office and MedPAC are also required to evaluate certain aspects of drug pricing in relation to PBM reforms included within the bill.
The package includes a series of changes to the Medicaid program, including new limits on provider taxes, penalties for states that allow Medicaid coverage of undocumented immigrants, cost-sharing requirements for Medicaid enrollees, and more frequent enrollee eligibility checks. Approximately 7.6 million people would lose their Medicaid benefits through this bill, while 1 million would lose access to plans purchased through the Affordable Care Act marketplace.
The One Big Beautiful Bill Act (H.R. 1) is central to Republican's broader effort to implement key parts of President Donald Trump’s domestic policy agenda – including tax reform, energy development, and stronger border enforcement. The package now goes on to the Senate, where it is expected to undergo significant changes. Several Republican senators have already expressed concerns with the Medicaid-related provisions of the House package, making it likely that the health portions of the bill will be revised before final passage. If the Senate amends the reconciliation legislation, the House will need to vote on the amended legislation, or the package would need to be reconciled via the conference committee process. Republicans aim to have the bill signed into law by July 4.
| MA Prior Authorization Reform Bill Reintroduced | | |
Senators Roger Marshall, M.D. (R-KS) and Mark Warner (D-VA) and Representatives Mike Kelly (R-PA), Suzan DelBene (D-WA), Ami Bera, M.D. (D-CA), and John Joyce, M.D. (R-PA) have reintroduced the Improving Seniors’ Timely Access to Care Act (S. 1816/H.R. 3514). This legislation has bipartisan support and aims to simplify the prior authorization (PA) process within the Medicare Advantage (MA) program.
The bill would: establish an electronic PA process for MA plans; increase transparency around MA prior authorization requirements; provide a pathway for the Centers for Medicare and Medicaid Services (CMS) to institute real-time decisions for routinely approved items and services; clarify CMS’ authority to establish timeframes for e-PA requests; expand beneficiary protections to improve enrollee experiences and outcomes; and require the U.S. Department of Health and Human Services to report to Congress on program integrity efforts and ways to further improve the e-PA process. CSRO is a member of a robust coalition of more than 150 stakeholder organizations in support of this legislation.
| | CSRO Meets with CMS Officials to Push for Step Therapy Reforms and SAD List Fixes | |
Last week, CSRO leadership met with Alec Aramanda, Principal Deputy Director of the Center for Medicare, and Joe Albanese, Policy Advisor at the Center for Medicare, within the Centers for Medicare & Medicaid Services (CMS), to discuss urgent policy reforms needed to improve patient access to rheumatologic therapies. The discussion focused on CMS’ 2018 step therapy policy and its impact on Medicare Advantage enrollees prescribed “underwater” biosimilars – products reimbursed below acquisition cost due to artificially low average sales prices. CSRO highlighted the access barriers this creates when physicians cannot afford to administer the preferred biosimilar, leaving patients without a viable treatment option. To address this, CSRO provided redline edits to the existing guidance, urging CMS to withdraw the policy entirely or, at a minimum, revise it to ensure timely access to clinically appropriate alternatives when the preferred product is financially unsustainable.
In addition, CSRO raised long-standing concerns with the Self-Administered Drug (SAD) Exclusion List, noting its impact on patients with physical or cognitive limitations and offering a series of policy recommendations aimed at restoring access and reducing unnecessary drug spending and waste, consistent with reports from the Office of Inspector General (OIG).
CSRO is closely monitoring these issues and will follow up with any new developments.
| CSRO Responds to Federal Agencies on Anticompetitive Healthcare Policies | | |
This week, CSRO submitted detailed comments to the U.S. Department of Justice and the Federal Trade Commission highlighting how current Medicare policies and pharmacy benefit manager (PBM) practices are driving consolidation and threatening access to rheumatologic care. CSRO emphasized the need to tie Medicare Physician Fee Schedule updates to inflation, correct flawed budget neutrality policies, and reform biosimilar reimbursement to reflect real-world acquisition costs. Additional recommendations focused on rescinding Medicare Advantage step therapy policies for Part B drugs, revising the Self-Administered Drug (SAD) Exclusion List, and mitigating the burden of overlapping audits and chart reviews. CSRO also joined the Alliance of Specialty Medicine’s letter, reinforcing shared priorities around payment stability, regulatory simplification, and preserving access to independent specialty care.
| | Member Spotlight: NCRA Hosts Advocacy Day in Raleigh | | |
On May 20, the North Carolina Rheumatology Association (NCRA) hosted its State Advocacy Day at the Raleigh State House. The group met with several state legislators, including most of the General Assembly leadership and members of the healthcare committee, to discuss the need to advance prior authorization reform (H434, S315) and PBM reform (H163, S479). The Advocacy Day was particularly timely as the Senate Health Care Committee heard the prior authorization legislation (H434) in committee later that week. Meanwhile, the PBM reform bills have both passed their respective chambers and now await consideration in the Senate and House, respectively. The group also heard from Representative Grant Campbell, MD, board certified in obstetrics and gynecology (OB/GYN), who serves on the House Health Committee and House Appropriations, Health and Human Services Committee, and provided insights into the inner workings between the House and the Senate.
| | Want to highlight your state societies' activities? Email info@csro.info. | |
Want to learn more about the legislation introduced in your state? Visit CSRO’s Map Tool to find all of the new and enacted bills within CSRO’s policy priorities.
| |
| | |
What's Happening in the States
CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report of CSRO priority bills.
| Interested in learning more about CSRO’s engagement in the states? Visit our State Legislation Correspondence page to review the letters submitted to state legislatures on CSRO’s priority issues. | | |
AK
- Prior Authorization | Step Therapy (SB133): Sent to Governor
CA
- 340B Drug Pricing Program (AB1460): Referred to Committee on Health .
- PBM Reform (SB41): In Assembly. Read first time. Held at Desk.
- Prior Authorization (AB512): Read second time. Ordered to third reading.
- Prior Authorization (AB510): In committee: Held under submission.
- Prior Authorization (AB539): Referred to Committee on Health .
- Step Therapy (SB40): In Assembly. Read first time. Held at Desk.
CO
- 340B Drug Pricing Program (SB71): Sent to Governor
CT
- 340B Drug Pricing Program | Prescription Drug Affordability Board | Maximum Fair Price limit (SB11): Rules Suspended and Transmitted
- Biomarker Testing Coverage (HB6771): In Concurrence
DE
- Prior Authorization (SB12): Assigned to Economic Development/Banking/Insurance & Commerce Committee in House
- Prior Authorization (SB6): Stricken in Senate
IL
- 340B Drug Pricing Program (SB2385): Senate Committee Amendment No. 1 Pursuant to Senate Rule 3-8(b-1), the following amendments will remain in the Committee on Assignments
LA
- Rebate Pass Through | PBM Reform (HB264): Read second time by title and referred to the Committee on Insurance.
MA
- 340B Drug Pricing Program | Step Therapy (SB868): Hearing scheduled for 06/02/2025 from 11:00 AM-03:00 PM in Gardner Auditorium
- Prescription Drug Affordability Board (SB875): Hearing scheduled for 06/02/2025 from 11:00 AM-03:00 PM in Gardner Auditorium
MD
- Copay Accumulator Adjustment Program Ban | Maximizer Program Ban | Alternative Funding Program Ban (SB773): Signed by Governor (05/20/2025)
- Prescription Drug Affordability Board (HB424): Signed by Governor (05/19/2025)
- Prescription Drug Affordability Board (SB357): Signed by Governor (05/19/2025)
- Step Therapy (HB848): Signed by Governor (05/19/2025)
- Step Therapy (SB474): Signed by Governor (05/19/2025)
- Step Therapy (HB820): Signed by Governor (05/19/2025)
ME
- Prescription Drug Affordability Board (SP314): Unfinished Business
- Prior Authorization | Biomarker Testing Coverage (HP72): On motion by Senator, placed on the special appropriations table pending enactment in concurrence
| | |
MO
- Copay Accumulator Adjustment Program Ban (HB474): Adjourned Sine Die 05/14
- Step Therapy (HB877): Adjourned Sine Die 05/14
MT
- Step Therapy (SB483): Adjourned Sine Die 04/30
NC
- Non-Medical Switching (H434): Re-ref Com On Rules and Operations of the Senate
NE
- Prior Authorization (LB77): Placed on Final Reading
NH
- Biosimilars (HB117): Committee Report: Ought to Pass with Amendment # 2025-2325s, 06/05/2025; Vote 5-0; CC; SC 24
NV
- Gold Card | Step Therapy (SB495): From printer. To committee.
NV
- Maximum Fair Price limit (AB259): In Senate. Read first time. Referred to Committee on Finance. To committee.
- PBM Reform (SB389): From printer. To re-engrossment. Re-engrossed. Second reprint. To Assembly. In Assembly. Read first time. Referred to Committee on Commerce and Labor. To committee.
- Step Therapy (SB294): (Pursuant to Joint Standing Rule No. 14.3.3, no further action allowed.)
NY
- Prior Authorization (S5209): PRINT NUMBER 5209A
- Step Therapy (A7522): PRINT NUMBER 7522A
OH
- Prior Authorization (HB220): House Insurance: 1st Hearing
OK
- 340B Drug Pricing Program (HB2048): Vetoed 05/17/2025
- Biomarker Testing Coverage (HB1810): Becomes law without Governor's signature 05/25/2025
- Prior Authorization | Step Therapy (HB1808): Sent to Governor
OR
- 340B Drug Pricing Program (HB2385): Third reading. Carried by Patterson. Passed. Ayes, 17; Nays, 13--Anderson, Bonham, Broadman, Girod, Hayden, Linthicum, McLane, Nash, Robinson, Smith DB, Starr, Thatcher, Weber.
- Prescription Drug Affordability Board (SB289): Governor signed.
RI
- Maximum Fair Price limit (S468): Referred to House Health & Human Services
TX
- Biomarker Testing Coverage (HB5178): Placed on General State Calendar
VT
- 340B Drug Pricing Program (H266): House proposal of amendment to Senate proposal of amendment
| | Mark Your Calendar: Upcoming Events
| | |
Virtual Advocacy Day: October 8, 2025
Save the date to advocate alongside CSRO as we host live conversations with health care leaders. Be notified when registration launches by clicking here!
| | |
Action Center
Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly.
Advocacy Council
Amplify your voice by assembling with other like-minded individuals to enhance CSRO’s advocacy initiatives.
Career Center
Locate the perfect fit whether you're looking for new career opportunities or trying to find the right candidate.
Explanatory Statement: “Underwater” Biosimilars
To aid in addressing the issue of "underwater" biosimilars with payers, CSRO has created a document to illustrate the extent of the problem.
Legislative Map Tool
Find your state on our interactive map tool to learn about current or proposed policy and ways you can take action to make an impact.
Payer Issues Reporting Form
Request assistance with any payer relation issues that may be impacting your patients or office.
Policy Correspondence
Easily access all of CSRO’s policy letters submitted to payers, state, and federal governments as an informational resource.
Rheum for Action
Learn about the latest advocacy issues in CSRO's advocacy column authored by Dr. Madelaine Feldman and produced in partnership with Medscape.
Step Therapy Cover Sheets
Review CSRO's state-specific step therapy materials that help guide practices in gaining an exemption from step therapy protocols.
| | |
Questions?
Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at info@csro.info.
| | | | |
