New York Issue News

• The Governor's office begins collecting budget requests from staff and state agencies - October. 
• Governor proposes a budget to the Senate & Assembly Legislature - January 21.
• The Senate & Assembly reply with their analysis of the proposed budget, called the "Blue Book" (Senate) and the "Yellow Book" (Assembly) - late January.
• The Legislature holds joint public hearings on the budget - late January through February.
• The Governor offers changes to the budget proposal based on legislative and public feedback; called "the 30-day amendments" - late February. 
• The Legislature offers their budget counter-proposals; called "one-house budget bills" - early March. 
• Legislators negotiate with the Governor's office on a final budget - through March.
• Final budget agreement approved by the Governor & Legislature - sometime in April.
• PLEASE NOTE that many of these dates often change with events.       

• Will end prescriber prevails for doctors under Medicaid.
• Will move Medicaid coverage of long-term nursing home stays for Medicaid patients out of managed care and to fee-for-service.
• Will expand "scope of practice" rules for Certified medication aides, medical assistants, pharmacy technicians, pharmacists, and physician assistants, to enable them to provide more care services and switch their licensing and oversight from the Education Department to the Department of Health. 
• Will allow NYS to join the Interstate Medical Licensure Compact and Interstate Medical Nurse Licensure Compact to increase the ability of NYS to recruit more medical professionals and nurses.   
• Will allow hospitals to create "acute hospital care at home" demonstration programs to show how certain care can be provided to patients in their homes. 
• Will examine and update health plan network adequacy requirements for state regulated health plans (the rules for health plan provider networks). 

CMS Will Negotiate More Medication Prices Source: HHS Press Release

CVS PBM Rolls out new drug pricing model Source: CVS press release.

All commercial prescriptions dispensed at CVS pharmacies will be processed through its CostVantage reimbursement model beginning this year, CVS announced Monday.

Under the model, prescriptions are priced based on the underlying cost with a delineated markup and dispensing fee to cover the services provided by CVS in the transaction. The company says this model makes it less necessary to raise the cost for certain prescriptions to cover losses on other drugs.

The model also seeks to increase transparency for insurers and pharmacy benefit managers, making it easier for PBMs to establish their own transparent programs for plans and clients. CVS Health said their team is also working to expand the program to Medicare and Medicaid prescriptions.

HHS Proposes cybersecurity updates to HIPPA Source: Fierce Healthcare website

The Department of Health and Human Services (HHS) proposed a rule days before the new year began to hold healthcare organizations to a higher standard for protecting sensitive healthcare information from security threats like cyberattacks targeting patient information.  

The proposal will require entities covered by the Health Information Portability and Accountability Act (HIPAA) to achieve specific technical standards like encryption and multifactor authentication. The rule also holds business associates to higher security standards and emphasizes that group health plans have a responsibility to protect electronic health information. 

ACA Enrollments set another record in 2025 Source: Fierce Healthcare website

More than 23 million people have selected coverage on the Affordable Care Act's exchange as part of open enrollment, according to data from the Centers for Medicare & Medicaid Services (CMS).

CMS said the 23.6 million sign-ups to date includes 3.2 million new enrollees, meaning the number of people with marketplace coverage has grown by 11.6 million since 2021. 

About 20.4 million people who had coverage in 2024 selected a new plan for 2025 or were automatically renewed in their previous plan, according to the agency. This continues to be on pace to set a new record for plan selections, according to CMS.

What do the ‘24 elections mean for people in NYS with rare disease?     

• The ACA (“Obama Care”) is also NY state law, so Congress can't repeal it here. However, Congress can end premium subsidies and limit coverage rules. This can lead to people losing good coverage, then they may spend down to qualify for Essential Plan or Medicaid coverage.   

• The new administration may support consolidation and less regulation., leading to more utilization management from health plans, (preauthorization, step therapy, etc.) and less robust coverage, both of which may then lead to more problems with Medicare advantage plans.   

• The new administration is not friendly to Medicaid. This can be a problem as NYS is a Medicaid expansion state and needs federal funds for Medicaid and Essential Plan. These programs cover approx. 8 million people in NYS. If Congress cuts Medicaid, the state will have to raise taxes and/or limit what they spend on care.  

• The recent Supreme Court Chevron ruling may limit what the incoming President can do if he seeks to loosen or reverse current health care regulations through administrative/agency actions.

• While one party controls Congress, many members must walk a fine line as they represent divided districts and face a midterm election in 2 years that tends to disfavor the party in power.