Health CARE Act of 2026
Sponsored By: Senator Warner, Mark R. [D-VA]
Introduced
Summary
Affordability across insurance and drug prices is the core goal of the Health CARE Act of 2026, which pairs permanent affordability fixes with sweeping price transparency, Medicaid stabilizers, and Medicare benefit expansions.
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- Families and consumers get stronger cost protections. The bill permanently extends enhanced premium tax credits, sets annual out‑of‑pocket caps for essential health benefits with a $2,000 prescription drug cap for self‑only plans in 2028, and limits insulin cost sharing to the lesser of $35 per 30‑day supply or 25 percent of the negotiated price.
- States and Medicaid programs gain new stability tools. The Act restructures enhanced expansion funding rules and creates an economic‑downturn FMAP boost that uses state unemployment increases multiplied by 4.8, capped so no FMAP quarter exceeds 95 percent.
- Providers, insurers, and drugmakers face new price rules and data requirements. Federal drug price negotiation expands and a negotiated “maximum fair price” can apply to private plans. Plans, hospitals, labs, and pharmacies must publish machine‑readable rates and face civil penalties for noncompliance, with hospital penalties ranging from about $300 per day up to persistent noncompliance caps totaling as high as $10 million.
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Bill Overview
Analyzed Economic Effects
7 provisions identified: 5 benefits, 1 costs, 1 mixed.
Lower drug bills and insulin caps
If enacted, group and individual plans would have new annual out-of-pocket limits for plan years starting January 1, 2028. The self-only prescription drug cap would be $2,000 in plan year 2028 and would be indexed later; other-than-self-only caps would equal twice the self-only amount. For covered insulin products, plans would not apply a deductible and would limit cost-sharing to the lesser of $35 per 30-day supply or 25% of the negotiated price, starting January 1, 2028. Cost-sharing for these insulin products would count toward your plan’s out-of-pocket maximum.
Medicare access, hearing, and drug talks
If enacted, Medicare would cover certain hearing tests and hearing aids starting January 1, 2028 for people with moderately severe or worse hearing loss. Medicare would pay for one hearing aid per ear every five years and require a written order. Medicare Advantage plans would face new prior-authorization reporting rules starting January 1, 2028 and must use secure electronic prior-authorization systems beginning January 1, 2029. The bill would also increase the number of drugs the government can pick for Medicare price negotiation in 2030–2032 and later years.
Stronger price and billing transparency
If enacted, plans and providers would have to give clearer cost information to people. Group plans would send detailed explanations of benefits within 45 days after a claim decision. Providers would have to tell patients how to request an itemized bill and provide itemized protected health information within 30 days at no charge. Hospitals, surgical centers, and plans would publish machine-readable price files and could face penalties for continued noncompliance, and plans would face audits of payment and rate files.
Low-cost individual plan and navigator help
If enacted, HHS would offer a coordinated low-cost health plan in the individual market starting in plan year 2028. The plan’s options could not cost more than comparable Exchange options, and the Secretary would set competitive provider payment rates with special attention to rural and underserved areas. For Exchanges run by the Secretary, $100 million a year from participating issuer user fees would be directed to navigator grants starting in fiscal year 2027 to fund in-person enrollment help and outreach.
Medicaid funding boosts and sequencing
If enacted, States with qualifying unemployment increases would get a higher federal Medicaid matching rate for fiscal quarters starting January 1, 2026. The FMAP boost would equal the State’s excess unemployment percentage points times 4.8, rounded to the nearest tenth, and no FMAP under this rule could exceed 95 percent. The bill would also change how enhanced Medicaid expansion matching periods are counted to consecutive 12-month periods and treat that change as if it applied retroactively. Beginning January 1, 2028, the Secretary could require certain Medicare or Medicaid providers to participate in a health plan as a condition of enrollment.
Repeal and rescission of recent health items
If enacted, the bill would repeal most of subtitle B of title VII of Public Law 119-21 while keeping a few named sections. It would also rescind unobligated amounts appropriated under the repealed provisions, including a listed Social Security Act subsection. The text does not state the dollar amounts or exactly which household benefits would change.
Drug-pricing, PBM, and pharmacy rules
If enacted, the bill would tighten rules for pharmacy benefit managers and make state Medicaid drug contracts use pass-through pricing for covered outpatient drugs starting 18 months after enactment. The government would run monthly national surveys of pharmacy acquisition prices and publish benchmarks, with retail surveys starting about 6 months after enactment and non-retail rules phased in later. The bill would change how manufacturers report units for certain rebate and inflation calculations and require more data access by plans and fiduciaries. These steps aim to lower drug prices and raise transparency but also add new reporting duties and penalties for some firms.
Sponsors & CoSponsors
Sponsor
Warner, Mark R. [D-VA]
VA • D
Cosponsors
There are no cosponsors for this bill.
Roll Call Votes
No roll call votes available for this bill.
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