“On a scale of 1 to 10 of my annoyance with taxes in general, this one is about a 2,” she said. “I see the benefits.”

The small surcharge on wages provides the funding for Washington Cares, the nation’s . It was set to begin distributing benefits July 1.

If Haggett, 67, a systems administrator who lives in Auburn, Washington, needs help with daily activities as she ages — bathing, dressing, grocery shopping, managing medications — she’ll be able to use the benefit she has accrued through WA Cares, as the program is known.

About 3.7 million workers participated last year, paying an additional 0.58% in payroll taxes. Those who contribute for 10 years will qualify for a lifetime benefit of $36,500. The amount will rise with inflation: A 36-year-old now earning about $50,000 a year who contributes $291 a year for a decade will have if she needs assistance at age 75.

Both the WA Cares mandatory premiums and eventual benefits are modest. But for older adults and people with disabilities, they can help pay for a variety of services: home care, transportation, adult day programs, home modifications like ramps and grab bars, compensation for family members who assist them, or assisted living facilities and nursing homes.

Haggett had looked into private long-term care insurance to cover those needs, but she balked. “It’s crazy expensive,” she said. And since premiums can rise, and frequently have, “you’re basically saying, I’ll pay whatever, whenever.”

Haggett knows that WA Cares can’t cover all her long-term care costs. In fact, because she was already in her 60s when payroll deductions began in 2023, and because she is planning to retire in two years, she’ll receive only half the lifetime benefit.

But “if I required care and it would protect my wife from having to spend our savings, $18,250 is not meaningless,” she said.

Washington has been working toward implementing WA Cares for a decade; the program has survived two statewide votes aimed at overturning or weakening it. Now, other states will be paying attention.

‘Most People Have Nothing’

An estimated 70% of Americans will need long-term care at some point in their lives, but “they haven’t planned for it or saved for it,” said Cathleen MacCaul, advocacy director for AARP Washington State, which supported the legislation that created WA Cares.

“People are under the misconception that Medicare will pay for this,” MacCaul said. In fact, while Medicare pays for healthcare, it rarely covers long-term care, either at home or in facilities.

Medicaid does cover long-term care, but it involves such strict limits on income and assets that “most middle-class people are left out, or they have to impoverish themselves” by spending nearly all their assets to qualify, said Richard Frank, director of the Center on Health Policy at the Brookings Institution. Those who are eligible often face lengthy waiting lists for care at home.

“Long-term care is the largest area of unprotected health risk in the United States,” Frank said. “Most people have nothing.”

Previous efforts to establish public long-term care protections have foundered. In 2010, the Affordable Care Act included , a legacy of Sen. Ted Kennedy that would have created a voluntary long-term care insurance program. The Obama administration eventually deemed it unworkable, and “it never saw the light of day,” Frank said.

The private market has also contracted. Most of the largest companies selling long-term care insurance — Genworth, John Hancock, MetLife — have exited the market. The return on their investments plummeted when interest rates fell after the Great Recession, and the number of insured people who abandoned their policies — a profitable development for insurers — was far below projections.

“The psychology of the industry was: Holy smokes, we’re losing money! We’re getting out,” said Claude Thau, who directs the annual Milliman Long-Term Care Insurance Survey. As the losses mounted and premiums spiked, consumers such as Haggett stopped buying policies. Moreover, Thau estimated, 1 in 6 applicants are unable to get coverage for health reasons.

Thus, fewer than 35,000 Americans bought stand-alone policies in 2024, compared with about 235,000 in 2010, according to a , a trade association. The average 60-year-old purchaser would, at age 80, receive a projected maximum benefit of $369 a day, Milliman reported. But the average annual premium on new stand-alone policies in 2024 — $3,265 — can seem daunting to someone close to retirement.

As the purchase of stand-alone policies has dropped, insurance companies have turned to policies bundling some long-term care benefits with life insurance or annuities. Those sales figures are climbing. Still, the association notes, only 3% of Americans age 50 or older have any long-term care insurance.

‘A Five-Alarm Fire’

That has prompted a recent spate of proposals to find public ways to protect Americans from ruinous costs that can continue for years. “This is a five-alarm fire,” said sent in May by U.S. Sen. Ron Wyden of Oregon and 16 fellow Senate Democrats to their colleagues.

The letter, more a statement of purpose than a specific legislative plan, proposed a “home care guarantee” for Medicare beneficiaries, among other efforts. Proponents expect to issue a more detailed report in the fall and to introduce a bill early next year.

A also proposed providing subsidized long-term care at home through Medicare, with beneficiaries making contributions according to their ability to pay. Like most of these programs, it would kick in when people need help with activities related to daily living or require supervision because of cognitive decline. The authors estimate that 8.2 million Americans will be eligible, far more than those who qualify for home-based care under Medicaid.

In the House, Rep. Tom Suozzi, a Democrat from New York, and Rep. John Moolenaar, a Republican from Michigan, have to create a catastrophic-insurance program for older people with disabilities. It would require them to pay for care out-of-pocket or with private insurance for the first several years before they would receive a monthly federal benefit.

Enacting federal initiatives in the current political climate seems unlikely, proponents acknowledge. The Trump administration’s plan to cut billions of dollars from Medicaid “has moved the needle backward on the accessibility of long-term care,” said Taylor Harvey, a spokesperson for the Senate Finance Committee.

So “are looking at what Washington is doing with a lot of interest,” said Norma Coe, who is an economist at the University of Pennsylvania and is tracking long-term care programs. Legislators have introduced bills in Illinois, Hawai‘i, and West Virginia; other states have task forces studying the issue.

“Long-term care is one of those conversations around every dinner table,” said Bea Rector, assistant secretary for the Department of Social and Health Services’ Home and Community Living Administration.

“Families step in,” she explained. Sometimes they can continue providing care, “but sometimes more formal care has to be put in place. That’s when people see the value of programs like this.”

Steven Russakoff knows the challenges of elder care, having provided years of support for his father, who died two years ago, and for his mother, who is now living in a nursing facility. “It’s brutal, it’s exhausting, and it’s extraordinarily expensive,” he said. The family has liquidated virtually all his parents’ assets to pay for their care.

Russakoff, who is 56 and lives in Shoreline, Washington, initially disliked WA Cares. He could handle the additional deductions (about $250 a year) from his paycheck as a director of university dining services, but he felt forced into a program he couldn’t use if he left the state to retire.

But WA Cares has already been amended several times and for many participants who move away, making him a convert. “It’s a good idea,” Russakoff concluded. “A necessary evil.”

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So he didn’t know he had a bill to pay. After he and Tix returned home to Minnesota in April, they got a letter from Wellcare, the insurer that provided his drug plan, saying his coverage had been terminated after three months of unpaid premiums totaling $28.80. Under Medicare’s rules, he can’t enroll in a plan again until the fall, for coverage beginning in 2027.

Pare takes Xarelto, a blood thinner that reduces his risk of strokes, blood clots, and pulmonary embolism. “He could bleed to death without it,” Tix said. A 90-day supply of the drug costs about $1,800 using a coupon from GoodRx, a discount drug website, she said.

Pare is among tens of thousands of Medicare beneficiaries who were on Wellcare’s Value Script drug plan who will likely go without prescription drug coverage for the rest of the year because they didn’t pay premiums for three months.

Next year, thousands more people in 32 states and Washington, D.C., who are enrolled in zero-premium drug plans from Wellcare and other insurance companies may find themselves in the same situation if their premiums go up and they don’t realize it, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of drug plan data. Premiums and other changes for 2027 will be unveiled in September.

Going without medication can be life-threatening, especially for Medicare beneficiaries. take one or more prescription drugs, according to the Centers for Disease Control and Prevention. Almost half live with four or more chronic health conditions that can cause functional or cognitive impairments.

Congress added prescription drug coverage to Medicare in 2003. But the coverage is administered by commercial insurance companies, which compete fiercely with one another for the business of about enrolled in drug plans.

Zero-dollar or very low monthly premiums have helped make Wellcare’s Value Script the bestselling stand-alone prescription drug plan in Medicare, with nearly 6 million customers across the U.S., according to government data. But in 26 states and Washington, D.C., some Value Script members who didn’t have to pay a premium last year were caught off guard by increases in 2026.

After a two-month grace period — which Wellcare extended to three — Medicare drug plans can drop customers who don’t pay their premiums, no matter how small the amount. Some members who lost their coverage in Nevada, for example, owed as little as $8.10 for three months, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis of Medicare drug plan data.

Wellcare terminated coverage for about 140,000 Value Script beneficiaries in April, according to a person with knowledge of the matter who was not authorized to speak publicly about it and feared reprisals at work for doing so. About 40,000 of the people who were dropped may be able to enroll in new coverage immediately because they have low incomes and receive financial assistance through a program Medicare calls “.”

Multiple state officials said they had heard the same disenrollment figures, including Nevada’s insurance commissioner, Ned Gaines, who chairs the National Association of Insurance Commissioners’ senior issues task force; Rebecca Gouty, director of the State Health Insurance Assistance Program in West Virginia; and Tim Smolen, director of Washington state’s Statewide Health Insurance Benefits Advisors. The West Virginia and Washington initiatives are part of the federally funded , or SHIP, which provides free, unbiased help navigating Medicare.

Surprise Bills

The Centers for Medicare & Medicaid Services, which oversees Medicare drug plans, declined to provide the number of Value Script members who lost coverage due to unpaid premiums. “The agency does not publicly provide plan-specific disenrollment figures or state-level breakdowns related to the non-payment of premiums,” Christopher Krepich, a spokesperson, said in a written statement to Ñî¹óåú´«Ã½Ò•îl Health News.

Centene Corp., Wellcare’s parent company, also declined to provide disenrollment numbers.

“We recognize how disruptive a loss of coverage can be and are committed to helping members understand their options,” said Sarah Baiocchi, senior vice president for specialty and prescription drug plans at Centene. She acknowledged that “some members in our Value Script plan experienced a premium for the first time, or for the first time in several years.”

Baiocchi said all Value Script members received a CMS-required annual notice of changes in September, before the premium increases took effect.

A sent to members in two states and Washington, D.C., is 21 pages long. The new premium is mentioned on pages 3 and 8, along with changes to out-of-pocket costs and how to find updates on covered drugs and network pharmacies.

The company also informed members about 2026 premium changes through phone calls, text messages, regular mail, or email, Baiocchi said.

People who are dropped are not able to reenroll or join another drug plan until the start of the open enrollment period this fall for coverage beginning Jan. 1, unless they qualify for an exception, Krepich said. And because they will have gone without coverage for at least 63 days, they could be hit with a permanent that increases every year for the rest of their lives.

“Medicare should be doing something about this so that we can go ahead and get coverage now,” said Wayne Bennett, 74, who lives in Durham, North Carolina.

In May, he found out that Wellcare had canceled his Value Script plan because he hadn’t paid his $3.60 monthly premiums. He takes nine prescription drugs to treat his blood pressure, glaucoma, chronic obstructive pulmonary disease, and other health problems. He filled most of his prescriptions — including several at no cost — before he lost coverage. He doesn’t know what he’ll have to pay when his supply runs out.

Gouty, the West Virginia program head, said many Medicare beneficiaries arrange for their monthly drug plan premium to be automatically deducted from their Social Security benefits, and that many likely thought that choice remained in place until they changed it.

“They didn’t realize that when the plan was a zero premium in 2025, that stopped the Social Security premium deduction and they would have had to reelect it for 2026,” Gouty said.

In other words, even if they mistakenly thought the premium was still zero, Medicare beneficiaries would have needed to somehow allow Social Security to make deductions — something the agency doesn’t do — or set up a payment plan through their bank or credit card in case payment was necessary.

“That sounds goofy,” Tix said.

Centene’s Baiocchi blamed the Social Security Administration for the problem: “We believe this was a key driver of non-payment disenrollments and subsequent complaints.”

Spokespeople for the agency referred questions about the matter to CMS.

Krepich said legal requirements for drug plan enrollment and disenrollment limit what CMS can do to help beneficiaries who lose coverage for not paying their premiums.

‘Pretty Upset’

Now that Pare has no prescription drug coverage, his doctor replaced his blood thinner medication with a much less expensive drug that should be just as effective. Pare paid $111 for four other medications that used to be free under his Value Script plan. He hasn’t had to refill four more prescriptions yet and doesn’t know what they will cost, Tix said.

If Wellcare members knew about the premium increases, they could have set up direct billing or an automatic payment plan early this year before the payment grace period ended April 1. But they would have been able to fill prescriptions during the grace period, so if they didn’t see Wellcare’s notices, they likely assumed there was no problem with their coverage.

Bennett, the North Carolina man, said Wellcare used to send him text messages with health tips and reminders when it was time to pick up a prescription. He didn’t know his premium had increased from $0 to $3.60 until it was too late.

“I was pretty upset,” he said, when he called the company. “The premium wasn’t that much, and I was ready to pay it right off the bat. I had my credit card out ready to make the payment.”

The customer service representative wouldn’t let him pay because his coverage had been canceled, Bennett said.

Hoping to restore it, Bennett called , a Durham nonprofit that advises Medicare beneficiaries and is one of more than 2,200 SHIP sites across the country. He was told he must wait until January to restart his drug coverage, said the group’s executive director, Gina Upchurch.

He doesn’t qualify for the “Extra Help” low-income subsidy or meet other CMS criteria for a , which would allow him to change drug plans during the year. CMS typically allows midyear switches for beneficiaries who, for example, move out of their plan’s service area, experience a natural disaster, or get help paying for drugs from a .

Senior PharmAssist was able to help one of its participants join another drug plan after she lost Value Script coverage because she is in North Carolina’s pharmacy assistance program for people with HIV/AIDS and has limited income, Upchurch said.

A further exception allows any Medicare beneficiary to enroll at any time in a drug plan that has earned five stars, the top grade in Medicare’s performance ratings. However, there are no five-star Medicare drug plans available to the general public. Only two insurers offer five-star plans, and only for retirees from certain employers. Their combined enrollment is about 8,700 as of June 1, according to the insurers.

But Upchurch, with more than two decades of Medicare expertise, doesn’t blame beneficiaries for not paying attention or for assuming Wellcare’s messages were bogus. Older adults are particularly vulnerable to identity theft and other scams and are often advised to ignore junk mail and calls from telemarketers.

Since Value Script members such as Bennett continued to get their prescriptions filled during the payment grace period, “why wouldn’t they think this was a scam?” Upchurch asked. “They are constantly bombarded by people selling them something that’s illegitimate or trying to scam them.”

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By the end of the month, she was in a hospital bed.

Hvatum, a part-time computer science professor, has a weakened immune system due to a rare condition known as primary immunodeficiency, which makes it difficult for her body to fight infections. Prior to her 2005 diagnosis, she had four bouts of shingles, a painful rash caused by a virus.

For more than a decade she relied on an expensive medicine to treat her chronic condition — and relied on her insurance to pay for it.

Then the denial letters came.

The Medical Service

To give her weakened immune system a boost, she relies on Hizentra, which is made up of antibodies collected from donated blood plasma.

At her home, near St. Louis, Hvatum can administer the complex medicine herself. She uses a large syringe to draw the medicine from a vial and loads the syringe into a plastic apparatus that looks like a toy Nerf gun. She cranks a blue plastic dial that triggers a steady drip of the medicine, and it snakes through plastic tubing until it enters her leg through a needle.

The Bill

$8,141.94: The full charges for a 28-day supply of Hizentra without insurance coverage.

After her Medicare Advantage plan through Humana denied payment for the drug in January, she missed several weekly doses.

The Billing Problem: Prior Authorization

Hvatum got tangled up in the controversial process known as prior authorization, which often requires patients or their medical team to get an insurance company’s approval before obtaining medicines or treatment. 

At the start of the year, after Hvatum switched Medicare Advantage plans, she received a letter saying that Humana, her new carrier, had denied her “prior authorization prescription request” for Hizentra. The authorization from her previous insurer didn’t carry over. 

Without the medicine, Hvatum developed a urinary tract infection that sent her to the emergency room on Jan. 30. Though it is a common infection, her doctor advised her to go there because people with her condition can get sick and deteriorate quickly, she said. 

That ER visit turned into an overnight hospital stay. That turned into hospital charges of more than $18,000, and again her insurance denied payment, saying this time that she wasn’t sick enough to require hospital care.

Hvatum’s experience with prior authorization is not unique.

Medicare Advantage plans reviewed nearly 53 million prior authorization requests in 2024, . That’s equivalent to nearly two reviews for every person enrolled in the program.

It’s common for Medicare Advantage plans to deny payment for care — which helps them make a profit, said Carrie Graham, director of the Medicare Policy Initiative at Georgetown University’s Center on Health Insurance Reforms.

The government pays a monthly sum to Medicare Advantage insurers to cover care for each member. “They make a profit if the care that person receives in that year is less than the amount they receive,” Graham said.

More than half of eligible Medicare beneficiaries choose Medicare Advantage insurance coverage. In 2026, roughly 35 million selected one of these private policies offered by insurance companies.

Humana is a dominant player in the space. Nearly half of all Medicare Advantage enrollees nationwide are covered by UnitedHealth Group or Humana, according to KFF.

The killing of UnitedHealthcare CEO Brian Thompson prompted renewed scrutiny of prior authorization. Last summer, months after his death, the nation’s largest insurers, including Humana, signed a pledge that outlined a handful of commitments to ease the burden on patients.

For example, insurers vowed to reduce the number of services that would require prior authorization approval. They also promised to reduce delays by honoring existing prior authorizations for a 90-day period when patients switched plans.

That’s not what happened in Hvatum’s case.

Humana said this pledge to honor existing approvals comes with limitations. “These commitments are for medical services only and do not apply to prescription medications,” spokesperson Mark Taylor said.  

Humana declined to comment on the specifics of Hvatum’s case, even though she agreed to waive her privacy rights, giving the insurer permission to comment.

While acknowledging that the prior authorization process can be deeply frustrating for patients, Humana said it “builds important checks and balances into the healthcare system by verifying that treatments and care delivery are in the best interest of patient safety and quality of care, while safeguarding taxpayer dollars.”

In July 2025, it would remove one-third of prior authorization requirements for outpatient services.

“We are committed to making the process faster and more seamless for patients and providers,” Humana said in a statement Taylor provided to Ñî¹óåú´«Ã½Ò•îl Health News.

The Resolution

Hvatum appealed, and Humana in late January reversed its initial payment denial for Hizentra, enabling her to afford her medicine again.

But the approval came with a catch: It expires at the end of the year, after which she would need to obtain approval all over again.

Hvatum has since switched to a different drug — and she might not stick around for any more medical-bill fights like this one. She and her husband are considering a move to Norway, a place with universal healthcare. He is a citizen there, which could give her a path to public health coverage.

The industry’s promises to change are too little, too late for Hvatum. 

By her account, she has done her part. Running is her outlet, maybe an obsession, and it keeps her healthy. Scores of medals and trophies are tucked about her home. Some sit on a white wicker end table, next to family photos, candles, and framed St. Louis Cardinals memorabilia. Above a large bay window in the kitchen, medals hang from ribbons of all colors, made to look almost like custom window drapery.

“I have done everything I possibly can to be healthy,” Hvatum said, sitting at her dining room table in her running gear. Her printed T-shirt read, “If found on ground, please drag across the finish line.”

The Takeaway

Data shows patients should appeal prior authorizations, because those who do often get their denials reversed, Graham said. In fact, 81% of Medicare Advantage appeals were partially or fully overturned in 2024, according to KFF.

Relatively few people appeal, because “it’s an exhausting process,” Graham said. It puts the onus on patients — and doctors get frustrated, too.

It’s not just Medicare Advantage plans that subject enrollees to prior authorization approvals. It’s prevalent in other types of coverage, and it has prompted blowback from the public. Graham believes the public outcry instigated the industry’s pledge to change.

Hvatum is well versed in filing appeals. She submitted another appeal to Humana after the insurer denied payment for her January hospital stay. Humana again reversed its denial of payment in her case.

Hvatum blames Humana for her January trip to the hospital. Had Humana approved her Hizentra, she said, she could have avoided hospital care altogether.

In March, she had a stroke. Humana denied coverage of that hospital stay, too.

Humana determined that it was not reasonable for the physician who admitted Hvatum to think she would need to stay at least two nights, the threshold for approval. “You had a small stroke,” Humana’s denial letter stated.

Hvatum noted the letter was dated March 25, two days after she was hospitalized. Humana reversed its denial two weeks after Hvatum appealed.

“They love to send you the denials fast,” Hvatum said. “Approvals take longer.”

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Elevance Health, which covers about 2 million people on Medicare, sent the money to the Centers for Medicare & Medicaid Services via wire transfer on May 27, court records show. Government lawyers disclosed the payment in a June 22 court filing.

In an email to CMS staff, Elevance described the money as a “remittance of the total overpayment amount” estimated by government audits, court records show. Company spokesperson Leslie Porras told Ñî¹óåú´«Ã½Ò•îl Health News in a statement that Elevance Health “continues to engage in constructive dialogue” with CMS. “We remain optimistic that a resolution can be reached and value our longstanding relationship with CMS,” she said.

The payment was made in response to a , in which the agency threatened to halt enrollments in Elevance Medicare Advantage plans unless the company corrected what CMS called “substantial and persistent noncompliance” with federal regulations that require health plans to submit accurate billing data and return any overpayments when they are discovered.

It appears to be the first time CMS has successfully pressured a Medicare Advantage health plan to pay back tens of millions of dollars in alleged overpayments — even though agency officials have known for years that many health plans have overbilled the program, according to audits by government staff.

“I’ve never heard of something like this before,” said David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm. “Usually plans seem to tie everything up and try to delay any repayment of anything for years.”

David Meyers, an associate professor at the Brown University School of Public Health, called the payment “substantial” and “a step in the right direction” toward holding the industry accountable.

“It’s a big win for CMS to get that much,” he said.

More than , about 55% of people on Medicare, have signed up for the private Advantage health insurance plans, which offer extra benefits, such as hearing aids and dental coverage, that traditional Medicare doesn’t cover.

Joining the plans may also prove cheaper for patients than purchasing a supplemental insurance policy that covers gaps in traditional Medicare.

Whether Medicare Advantage is a good deal for taxpayers is hotly debated, however.

The health plans have been the target of dozens of and government investigations alleging they often exaggerate how sick patients are to improperly boost their payments, claims the industry disputes. Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.

Researchers also have concluded that Medicare overpays the health plans by billions of dollars every year because of medical coding flaws that generate higher bills than are justified.

The whistleblower suits, mostly filed by former employees of healthcare companies, have long served as the primary tool for clawing back alleged overpayments. In January, Kaiser Permanente to settle Justice Department allegations that it billed the government for medical conditions patients didn’t have, the largest such penalty to date. In a on its website, the company said it settled the case “to avoid the delay, uncertainty, and cost of prolonged litigation.”

By contrast, CMS’ efforts to prevent Medicare Advantage plans from overcharging have largely foundered.

In 2014, for instance, CMS backed off a proposed regulation that would have cracked down on overbilling amid an “uproar” of opposition from the industry. And even when CMS audits uncovered tens of millions of dollars in overpayments, agency officials of that amount.

The CMS threat to bar Elevance from enrolling new members may open a new approach.

“The payment Elevance is making here is not trivial,” said Matthew Fiedler, a health policy researcher at the Brookings Institution.

But he noted that it represents a very small fraction of the total the company receives from Medicare. He said that making a big dent in the overpayment problem would require CMS to collect “many similar payments” — from “every” Medicare Advantage insurer.

“I don’t think there’s a clear reason to believe that at this stage,” Fiedler said.

Richard Kronick, a former federal health policy official and a professor at the University of California-San Diego, agreed that the payment reflects a small portion of the company’s revenue. But he said it was “still a sizable check to write.”

Kronick said the action reflects “perhaps a bit of muscle flexing” by CMS to tighten up enforcement.

CMS did not immediately respond to a request for comment. It’s not clear from court records whether the payment will end the CMS threat to ban Elevance from signing up new members.

If so, it might prove to be a relative bargain. In with the Securities and Exchange Commission, the company noted that its “current best estimate” of the “potential exposure” in the case was approximately $935 million.

Elevance has been at odds with the federal government over its billing practices since 2020, when the Justice Department filed a against the company, then known as Anthem. That case is pending.

Court filings in that case disclosed the company’s payment to CMS. In an email made part of the court file, a company official confirmed it had sent the wire transfer in the amount of $342,209,085.30 on May 27 and said the payment was related to the threatened enrollment ban. The company also stated that it was challenging the CMS enforcement action and called it “unprecedented.”

In defending against the Justice Department suit, Elevance has denied wrongdoing and argued that CMS knew about its billing practices for years and took no action.

Meyers, the Brown University professor, said CMS’ success in collecting payment from Elevance may encourage more enforcement.

“It remains to be seen whether this is a sea change,” he said.

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Even the bill’s backers say securing passage this year is a long shot. But the effort is one more opportunity for Democrats to highlight voters’ frustration about healthcare costs leading into the November election.

Polls show Americans are very concerned about affordability, with finding fewer than half of Americans say they can consistently afford healthcare.

Wyden’s bill would focus on what many consider a critical pocketbook issue in traditional Medicare: There’s no limit on what a beneficiary could pay in cost sharing.

“Everyone else in the health insurance neighborhood has one — employer coverage, the Affordable Care Act, all of them have a cap,” the Oregon Democrat told Ñî¹óåú´«Ã½Ò•îl Health News. “There’s no good, common-sense reason why the flagship health program doesn’t have the same protection.”

Critics of a cap, meanwhile, are likely to pounce on the cost to the federal budget, which could be significant.

Wyden, already making the battle lines clear, added, “I suspect it will come up on the floor of the Senate that Democrats want to give a fair shake to people on traditional Medicare and Republicans want to help billionaires.”

Policy, Political Dynamics at Work

The underlying issue is the 20% share of have to pay for medical services after they’ve met any deductibles. Without a ceiling or upper limit, an expensive condition such as cancer or a long hospital stay could result in beneficiaries paying thousands of dollars in costs.

That concern leads enrolled in traditional Medicare to purchase separate insurance, often called Medigap. (Others get such coverage through job-based retiree plans.)

Medigap insurance plans have seen rapid premium increases and can cost thousands of dollars a year, especially for couples. That price tag can be unaffordable for some beneficiaries, who may instead turn to private-sector Medicare Advantage plans offered by commercial insurers, or go without.

The Wyden proposal would set a $5,000 cap in traditional Medicare. Any amounts paid by a Medigap plan or a retiree health plan toward beneficiaries’ care would count toward that cap. It also includes other provisions to help older people with lower incomes, including eliminating an asset test to qualify for special programs that help reduce costs.

Medicare would pick up any amounts over that $5,000 limit, which is lower than the one Congress set for the rival Advantage plans — , although insurers can set smaller amounts.

Setting a cap in the traditional program, proponents argue, would help level the playing field between traditional Medicare and Advantage plans, which often cost consumers far less than traditional Medicare with a Medigap supplement. Premiums for these policies would probably be lower, they say, because the insurers’ financial exposure would be limited.

The Medicare Advantage program has historically had strong support from Republicans, who like its private-sector aspect and note that it can potentially do more to control costs, such as by using specific networks of doctors and hospitals, or requiring preapproval for some services, which the traditional program cannot do.

The plans also offer enrollees additional benefits, such as eyeglasses, hearing aids, and prescription drug coverage, and have now attracted more than .

Along with that growth, however, has also come increased scrutiny over concerns about denials of patient services and the to the traditional program. Recently, some health systems have , citing concerns about tardy payments or prior authorization requirements, while insurers where they offer Advantage coverage.

The bill has not yet been analyzed by the Congressional Budget Office, so there is no official estimate of increased costs to taxpayers for Medicare. Still, it would raise those costs — at a time when other health programs are being cut, the Medicare trust fund is scheduled to of funding in 2033, and the .

That is likely to draw sharp rebukes from fiscal hawks and other conservatives who question whether billions in tax dollars should be used to pick up costs that would otherwise be paid by enrollees or by the supplemental insurance plans many purchase to do so. They are likely to note that beneficiaries could also choose to join private sector Advantage plans, which eliminate the need for supplementary insurance coverage such as Medigap.

Key Questions: Who Benefits? Who Pays?

A cap’s cost to taxpayers, while not officially scored yet, is likely to be significant, although adding one could also save individual consumers money. A recent study from Brown University gives some clues.

A $5,000 cap could save enrollees , the study says, both in direct savings and reductions in their Medigap supplemental premiums. Just over 11% of traditional Medicare beneficiaries, about 3.2 million, would directly benefit from such a cap if it was implemented in 2028, said the study, which did not receive outside funding.

Over the next 10 years, it estimates, just over 52% of all traditional beneficiaries would exceed the $5,000 cap at least once.

Still, lead author Andrew Ryan, a professor at Brown’s School of Public Health, said analysts estimated such a cap “could cost over $50 billion annually, which is a lot of money” to add to the federal balance sheet.

Critics are likely to focus on the cap’s expense and the number of people who might benefit.

“How many people are hitting a level of cost they can’t afford on Medicare? “asked Jackson Hammond, a senior policy analyst with the Paragon Health Institute, a conservative think tank influential with the GOP.

Any cap “is generally going to increase expenses for the program without adding a lot of benefits to enrollees,” said Hammond, who spoke with Ñî¹óåú´«Ã½Ò•îl Health News before the legislation was introduced.

Supporters, though, have a different view.

Certainly, with “any policy that’s going to cost money, there will be an argument over where the money is coming from,” said Brian Keyser, a research associate at the liberal Center for American Progress who also spoke with Ñî¹óåú´«Ã½Ò•îl Health News before the Wyden measure was introduced.

Keyser co-authored that suggested lawmakers could pay for changes in traditional Medicare, such as an out-of-pocket cap, if they reduced the amount the government pays Medicare Advantage insurers, pointing to government estimates that Advantage would cost the government $76 billion more this year than if the same number of people were in the traditional program.

Finding a way to add a cap “is right and fair because without it, people who become seriously ill can spend their life savings on cost-sharing Medicare,” Keyser said.

Such an idea, however, on and off for years. Knowing that, the bill’s backers acknowledge that passage is unlikely — but they say they’re playing the long game for now.

“We’re going to push for it in the next Congress, when we believe we will be in the majority,” Wyden said.

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But this year, because of a new Medicare program, Curry has traveled a little more often.

In February, during one trip, he was told unexpectedly that he needed preapproval for the procedure. Then he went again a month or so later to get the injection, for a total of 10 hours on the road. His clinic wanted him to come in a third time, which they had never asked of him before. That appointment was “just to fill out a piece of paper to tell them how you feel again,” Curry said, so he hasn’t gone.

In January, Oklahoma became one of six states to begin a pilot program testing the use of preapprovals in traditional Medicare, the federal health insurance program for people 65 and older or with disabilities. Medicare had previously eschewed the practice — also known as prior authorization — which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions.

Epidurals like Curry’s are among 13 medical services subject to the new program because the Trump administration says they’re prone to fraud or misuse. Powered by artificial intelligence, the program — called the Wasteful and Inappropriate Service Reduction Model, or WISeR — is intended to save the federal government money and protect patients from potentially unsafe or unneeded care.

Yet early reviews from Oklahoma and the other pilot states — Arizona, New Jersey, Ohio, Texas, and Washington — suggest WISeR’s rollout has not been smooth. Patients, doctors, and other healthcare professionals who spoke with Ñî¹óåú´«Ã½Ò•îl Health News say the effort has created confusion, errors, long wait times, and stress. Some described the rollout as “horrendous” and say people enrolled in Medicare in the pilot states are now getting ensnared in the same red tape as those with private insurance.

One key concern is that it all happened too hastily. WISeR was and launched in mid-January.

That was “quicker than normal” for the federal government, said Todd Baker, who recently stepped down as CEO of the Ohio State Medical Association. Doctors “just sort of had to figure it out,” added Jeb Shepard, director of policy at the Washington State Medical Association.

Government contractors have also acknowledged the rapid pace. “We’ve had an aggressive rollout from the time of being notified to going live,” said Jeremy Friese, CEO of Humata Health, the vendor for Oklahoma. Tech executives servicing other states have said they were still adding features to their products in the spring.

Abe Sutton, director of the Center for Medicare and Medicaid Innovation, which is administering the program, didn’t comment on the rollout schedule. But he said in a statement that the goal of these reforms is to ensure that prior authorization is efficient, fast, and streamlined.

“The model aims to reduce inappropriate care without delaying appropriate care,” he said.

Mehmet Oz, the leader of the Centers for Medicare & Medicaid Services, that they were “rolling out some prior authorization on abused practices.”

“The purpose of these is not to deny care,” Oz continued. “It’s to make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to use on you.”

Medicare has struggled in recent years with suspected fraud associated with particular services. The Department of Health and Human Services’ inspector general spending on skin substitutes, for example, had surged nearly 700% over two years, raising “major concerns about fraud, waste, and abuse.” Skin substitutes are among the currently subject to review under WISeR.

The program also imposes prior authorization requirements for kyphoplasty, a surgery for spinal fractures, which a report by the Medicare Payment Advisory Commission .

Sutton acknowledged, however, that “the percentage of providers committing waste, fraud, and abuse is small.”

Consumers and clinicians largely detest prior authorization. Even as federal health officials test the process for Medicare, the Trump administration is for those with private insurance. According to a conducted in January, 69% of insured adults consider prior authorization a burden for care.

Through WISeR, doctors and their staff log in to online portals to submit medical records that justify the procedures. Using artificial intelligence, the systems quickly approve applications that meet the program’s criteria, Friese, Humata’s chief executive, told Ñî¹óåú´«Ã½Ò•îl Health News. He said there is an “immediate yes” in 88% of cases for which clinical data supports an approval.

CMS has touted the process as one in which decisions are returned within 72 hours. After that, clinicians receive a “universal tracking number,” which allows them to schedule the procedure and get paid. In practice, however, participants say the process is anything but easy.

The University of Washington’s medical system alone had nearly 100 patients waiting earlier this year for epidural injections due to WISeR-related delays, from the office of U.S. Sen. Maria Cantwell (D-Wash.) that drew on hospital association data. “Now, patients are subject to delays or denials which did not exist prior to the WISeR Model,” the report said.

Curry, the Oklahoma cattle farmer, said he might go to Kansas for future treatments to avoid the approval process. Dorota Gribbin, a New Jersey-based physical medicine and rehabilitation physician, said that by the time authorization came for one of her patients who needed a back pain procedure, the patient had gone to the hospital for more expensive care.

Jennifer Valle, a precertification and insurance supervisor at Clinical Radiology of Oklahoma, said when it comes to kyphoplasties, there has been a lot of “nitpicking” from reviewers. Other times, information her practice provides to CMS gets overlooked, she said, and reviewers ask for imaging that’s already in the file.

Claims with no problems are supposed to be paid within 15 days, said James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, who has also been frustrated by the prior approval and reimbursement process for kyphoplasties. “Six- to eight-week delays is what we’ve been seeing,” he said.

“It’s been horrendous,” said Jerry Sobel, a Phoenix-area pain management doctor. “Right from the beginning, there seemed to be no organization.” Sobel said that as of May, he hadn’t gotten paid by Medicare for nine epidurals.

“We continuously monitor operations and work closely with stakeholders to address questions and improve the provider experience,” said Sundar Subramanian, the CEO of Zyter, which has the contract for Arizona.

During an April webinar, another Zyter executive acknowledged a large backlog in payments stretching to January. Those backlogs “are currently being resolved,” Medicare’s Sutton said, without providing further detail.

When asked about other issues — including what doctors suspect are AI-driven errors — Medicare’s Sutton said the agency appreciates “feedback on provider experience.” It will be used “to help providers better understand WISeR processes,” he said.

Although CMS vendors say humans make the final decisions on approvals, doctors and their staffs believe artificial intelligence is playing a large role in the process and that denials are sometimes the result of AI hallucinations that garble or make up information.

One Arizona doctor, who wasn’t authorized by his practice to speak, recalled a denial saying his patient wasn’t eligible for procedures in the thoracic region, or mid-back. The patient needed an injection to the neck. Webb, the Oklahoma radiologist, documented four times that a patient lacked numbness, and yet his WISeR application was still denied, citing numbness, which, in the reviewer’s interpretation, would rule out the spinal surgery procedure.

Friese, Humata’s CEO, said he hasn’t heard about any AI hallucinations.

The process is also raising government costs. With more rejections, more appeals are being filed with Medicare’s administrative contractors. The government pays the contractors to handle the appeals, and Medicare’s Sutton acknowledged that the agency has “accounted for potential changes in the volume of Medicare appeals because of the WISeR program and its associated costs.”

Eighty-four percent of commercial insurers already use AI tools, according to a survey released in 2025 by the National Association of Insurance Commissioners, though they have consistently said AI isn’t used to deny prior authorization requests.

Its use in Medicare risks introducing friction and frustration into the program — and piling costs onto its beneficiaries. Prior authorization saves money for insurers partly by making patients pay a price in wait times and inconvenience, said Miranda Yaver, a University of Pittsburgh health policy researcher studying the technique.

“People will end up getting ensnared in a lot of red tape, having to be on hold, and getting rerouted,” she said. She often wonders whether prior authorization simply shifts costs to patients and doctors, rather than saving them.

Some doctors involved in Medicare’s prior authorization experiment believe it will inevitably expand beyond a few services officials in Washington consider fraud-prone.

“Everybody knows that if this pilot project works, it will be prior auth for basically all procedures,” said Mary Clarke, a family practice physician in Stillwater, Oklahoma. “If they can show that they can save money, then that’s going to be extrapolated and rolled out to other procedures and multiple other things in other states.”

When asked whether CMS is considering expansion of its prior authorization pilot, Sutton said in his statement that there are “currently no changes” considered for the list of services subject to the WISeR program, “but CMS continues to assess whether any changes are warranted.”

Do you have an experience with prior authorization you’d like to share? to tell Ñî¹óåú´«Ã½Ò•îl Health News your story.

Ñî¹óåú´«Ã½Ò•îl Health News Southern correspondent Lauren Sausser contributed to this report.

This <a target="_blank" href="/medicare/medicare-ai-prior-authorization-wiser-delays-errors/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Under a law enacted last year, five of Indiana’s largest nonprofit hospital systems cannot charge patients covered by job-based health plans more than an established price cap. Hospitals that fail to keep prices below the threshold by 2029 risk losing their tax-exempt status — which would mean owing millions of dollars in state taxes.

Even before that penalty kicks in, the law requires these hospitals, which control nearly half the state’s hospital market, to offer direct-to-employer contracts — bypassing insurers — and stay within limits set by the state. Hospitals that don’t comply face a $10,000-a-day penalty.

Many other Indiana hospitals must comply with this provision beginning in September.

Indiana’s law comes amid growing frustration with rising insurance costs and hospital prices, the of growing healthcare costs.

Government price controls, of course, are nothing new in healthcare. Since the mid-1960s, the federal government has set prices it pays hospitals for treating Medicare enrollees, as states do for Medicaid patients. Those two government programs cover more than 135 million people nationwide.

But hospitals face no such government limit on what they charge for the more than 165 million Americans covered by employer-paid insurance.

Indiana isn’t the only state targeting hospital prices. Vermont also limits how much hospitals can charge for people covered by employer plans.

Washington and Oregon have made similar attempts, on a smaller scale, targeting state employee health plans. Oregon’s hospitals cannot charge the state employee plan more than two times the Medicare rate for services. This caps the state payment for a service at $200 if Medicare pays $100. Within the first two years, the plan saved more than $100 million.

Legislation has been proposed in Colorado and New York to enact similar price controls.

Hospital leaders and other opponents of price controls argue that the strategy doesn’t address the root causes of high hospital prices, such as rising labor, drug, and technology costs, and that the caps will force hospitals to cut services. Another challenge is that few employers contract directly with hospitals.

On most policy issues, Indiana and Vermont likely agree on very little, “except for this is one area where they both see that hospital prices are high,” said Brown University economist Christopher Whaley.

Wielding state power to control prices is a strategy typically led by Democrats. But Mike Braun, the Republican governor who helped muscle through the changes over the objections of the Indiana hospital industry, said the healthcare system is too broken to leave alone.

“Government has to intervene, because healthcare is run like an unregulated utility,” he told Ñî¹óåú´«Ã½Ò•îl Health News.

The five Indiana nonprofit hospital systems involved are Ascension St. Vincent, Community Health Network, Franciscan Health, Indiana University Health, and Parkview Health.

The price cap will be based on the statewide average for inpatient and outpatient hospital prices. Indiana will use Medicare as a yardstick by which to measure commercial prices, a comparison commonly used by researchers. This will show how much higher commercial prices are than the government program’s.

By June 30, the state is expected to issue a report showing average hospital prices in the state and where individual hospitals fall on the spectrum.

For years, have found that Indiana hospital prices are some of the highest in the nation.

The , produced in November, found three of the five nonprofit hospital systems exceeded a voluntary benchmark when excluding practitioner services, such as doctor fees.

However, all five hospital systems were below the voluntary benchmark when doctor services were wrapped into the overall score. This finding illustrates how prices for doctor visits may obscure overall hospital prices by bringing down the average, researchers and lobbyists for employers told Ñî¹óåú´«Ã½Ò•îl Health News.

Rand researchers found that while Indiana is home to some of the highest-paid hospitals, its doctors are among the lowest paid in the nation. That’s partly because the doctors don’t have the same negotiating leverage as the handful of large health systems.

This disparity has sparked a debate over which prices should be used to calculate the upcoming cap. Including doctor services would likely allow hospitals to keep prices high because they would be offset by low doctor prices, said Whaley, who has co-authored Rand’s pricing reports. This would let hospitals off the hook from doing the work to “move the needle” on lowering prices, he said.

Indiana Hospital Association President Scott Tittle said it’s unfair to exclude doctor services.

Hospitals often acquire physician practices to help drive admissions, . But Tittle said it also helps keep doctor offices open and preserves access for residents. That comes at a cost, he said.

“We know it is absolutely part of the complete cost of care,” Tittle said.

Despite the hospital lobby’s efforts, Tittle said, the state will exclude doctor services from the cap.

Regardless, Tittle said it’s unnecessary to put price caps in state law. “Hospitals can and have done the hard work to reduce their pricing,” he said.

For employers, rising healthcare costs are a headache. They’re unpredictable and make it difficult to budget each year.

Doug Bawel, chairman of Jasper Holdings, an automotive parts company based in Jasper, Indiana, has tried various strategies to wrestle high healthcare costs. For his workers, he’s purchased diabetes drugs from New Zealand and housed on-site health clinics.

Under the law enacted last year, Indiana hospitals must offer direct contracts to employers for a variety of procedures priced at or below 260% of what Medicare pays for hospital care. That’s setting a ceiling at slightly more than 2.5 times what Medicare pays.

Bawel expects the state’s price controls on direct deals to significantly strengthen his negotiating leverage with hospitals. He belongs to a consortium of southern Indiana employers that buy services directly from area hospitals.

This move represents a departure from the status quo for the business lobby. Ashton Eller, a healthcare lobbyist for the Indiana Manufacturers Association, said the group generally opposes government price controls. But it believes this is a step in the right direction, he said.

“Is this a silver bullet that will bring down prices overnight? We don’t pretend it is,” he said.

No matter what happens in the Hoosier State, Indiana’s experiment with price controls has attracted attention.

“As employers and states are dealing with double-digit premium increases, there is tremendous interest in healthcare affordability, and what happens in Indiana is being closely watched by many states and Washington, D.C.,” Whaley said.

This <a target="_blank" href="/health-industry/hospitals-price-controls-indiana-cap-healthcare-costs-debate/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Julie Rovner Ñî¹óåú´«Ã½Ò•îl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of Ñî¹óåú´«Ã½Ò•îl Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

When Congress failed to extend the covid-era enhanced subsidies for the Affordable Care Act, many experts predicted millions of people would lose coverage because they would be unable to make payments toward the higher premiums. It has taken a few months, but that prediction seems to be coming true.

Meanwhile, controversy in the medical community about how — or whether  â€” to work with the Trump administration burst into the open at the annual meeting of the American Diabetes Association, as members who were handing out an editorial criticizing the administration’s cuts to biomedical research were evicted from the event, prompting a backlash.

This week’s panelists are Julie Rovner of Ñî¹óåú´«Ã½Ò•îl Health News, Lizzy Lawrence of Stat, Sandhya Raman of Bloomberg Law, and Lauren Weber of The Washington Post.

Panelists

Lizzy Lawrence Stat

Sandhya Raman Bloomberg Law

Lauren Weber The Washington Post

Among the takeaways from this week’s episode:

• A from The Commonwealth Fund highlights enrollment declines in Affordable Care Act marketplaces, a trend experts predicted when Congress did not renew the enhanced ACA tax credits at the end of 2025. As consumers continue to struggle with rising costs for groceries, gas, and other expenses, individuals who lost that additional financial assistance to purchase health insurance may be facing higher premium costs and more out-of-pocket expenses.
• Concerns over the difficulty of implementing the administration’s Medicaid work requirements, along with potential legal challenges, may mean the regulations could be delayed or even reversed. For example, doctor and patient groups contend that the requirement that physicians determine whether each individual can work the required 80 hours per month will create unintended consequences, such as paperwork and bureaucratic hassles, for patients and their doctors, rather than decrease fraud in the program.
• On Capitol Hill, fewer days in session and more days on the midterm campaign trail, plus a lack of bipartisanship, likely mean that lawmakers may be less willing to find a path forward to strengthen the financial solvency of the Medicare and Social Security trust funds. The programs’ annual trustees’ report found that the two entitlement programs, which provide benefits to millions of people, will technically become insolvent in 2033. In recent years, lawmakers have been inclined to act only when facing an imminent deadline rather than taking action to avoid a future problem.
• Leaders of the American Diabetes Association apologized for having security escort several doctors and researchers, including the editor-in-chief of the association’s flagship medical journal and a past president of the ADA, from the group’s annual research meeting for distributing a journal editorial criticizing the administration’s cuts to biomedical research. The incident highlighted how fearful some nonprofit leaders are of taking on the Trump administration.

Also this week, Rovner interviews KFF’s Tricia Neuman, who is retiring this month as a senior vice president and the executive director of the Program on Medicare Policy. 

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: Ñî¹óåú´«Ã½Ò•îl Health News’ “Anguished Parents. Doctors in Tears. Utah’s Long Measles Outbreak Takes a Toll,” by Amy Maxmen.

Sandhya Raman: CIDRAP’s “,” by Liz Szabo.

Lizzy Lawrence: The Chicago Tribune’s “,” by Christy Gutowski and Gregory Royal Pratt.

Lauren Weber: ProPublica’s “,” by Annie Waldman.

Also mentioned in this week’s podcast:

• Politico’s “,” by Alice Miranda Ollstein and Robert King.
• The New York Times’ “,” by Sheryl Gay Stolberg.
• MedPage Today’s “,” by Kristina Fiore and Kristen Monaco.
• Stat’s “,” by Anil Oza.
• Fierce Healthcare’s “,” by Paige Minemyer.
• Stat’s “, Federal Investigators Find,” by Casey Ross and Bob Herman.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From Ñî¹óåú´«Ã½Ò•îl Health News” on , , , , , or wherever you listen to podcasts.

This <a target="_blank" href="/podcast/what-the-health-450-aca-enrollment-drops-june-11-2026/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Even as prescription drug costs rise, patients with commercial insurance have slowed their use of manufacturer-sponsored drug coupons in recent years, according to April 6 by the Journal of the American Medical Association.

Manufacturers are offering just as many of them, “but still, we see a lot of affordability issues among this commercially insured population,” said So-Yeon Kang, the study’s main author, who is an assistant professor of health management and policy at Georgetown University.

“Patients are at the intersection and battle place between these payers and manufacturers,” she said.

Drug manufacturers distribute copay coupon cards to consumers online or in person at the pharmacy counter. These manufacturer-sponsored coupons are not the same as discount card services from companies like GoodRx, which negotiate lower bulk pricing for prescription drugs, then pass those savings along to the consumer.

Manufacturers issue the coupons to keep their drugs competitive by offering patients short-term savings. Consumers pay less out-of-pocket, often for brand-name drugs. This encourages patients to use the brand-name version of the drug, even when a cheaper, generic version might be available.

Some insurers say this unfairly puts them on the hook for pricier drugs. They say monthly premiums are higher as a result, punishing consumers and patients, not the manufacturers.

So, should you use manufacturer-sponsored prescription drug coupons when they are offered?

The short answer: It depends.

Here are five things to consider:

1. What if you do not have insurance?

If you are uninsured, using a coupon can be a great way to save money, especially if there is no generic version of the drug.

TrumpRx is a new federally funded initiative that acts as a prescription drug coupon dashboard for patients. Some of the coupons come from manufacturers, while others do not. Not every drug has a coupon offer, but the portal will save consumers money on drugs for those that do, especially in the short term.

Michelle Long, a senior policy manager at KFF who studies patient and consumer protections, said people without insurance can save money by using TrumpRx or manufacturer coupons. (KFF is the health policy research, polling, and news organization that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

“I wouldn’t brush it off entirely because it’s got Trump’s name on it,” Long said. “For a lot of people who take certain medications, there really could be some real savings.”

Still, Long said, TrumpRx lists only about 85 drugs, among thousands approved by the FDA. It is important to note that drug coupons have limitations and guidelines. They do not last forever. When they are exhausted, uninsured consumers may have to pay full price for the drug.

2. What if you have commercial health insurance?

For people with insurance, the answer is a little more complicated.

If the drug isn’t covered by your insurance plan or if you intend to pay cash, then the coupon may be the way to go. If not, be wary.

Insurance coverage varies for certain kinds of drugs, such as GLP-1 obesity drugs. Kang’s study found that coupon use by commercial insurance holders on obesity drugs dropped from 54.6% of prescriptions in 2017 to only 2.5% in 2024, even though use of the drugs has been rising in the United States.

She said this reflects the growing number of patients paying cash for the drugs as prices decline, along with insurers’ reluctance to cover them and manufacturers’ shifting focus from coupon distribution to marketing campaigns.

3. What should you do if you expect high medical costs this year?

If you have insurance and anticipate meeting your deductible for the year through health care visits and treatments, consider using the coupons.

Coupons let you pay less out-of-pocket when you visit the pharmacy, but your insurer likely won’t count the value of the coupon toward your deductible. Only use a coupon if there is no generic option available and if you know you’d otherwise hit your deductible.

4. What if you have insurance but low overall medical costs?

The answer will almost always be: Don’t use the coupon.

Unless the drug you are looking for is not covered by your insurance plan, using coupons will put you at risk for higher indirect costs. It’s also often more advantageous to spend toward your deductible.

Watch out for copay adjustment programs that insurers use to discourage the use of drug coupons. They come in two common forms, Long said.

“” allow the use of drug coupons up to their full value, but the amount of the coupon won’t count toward patients’ deductibles or out-of-pocket maximums. That makes it harder for them to reach the threshold at which insurers will pitch in on prescriptions and other medical care. It can also mean a patient will eventually start paying the full cost of the drug because they haven’t yet met their annual deductible.

“Copay maximizers” use a similar technique that also prevents the coupon value from counting toward deductibles. Maximizer programs use a third party to over the course of a year to match the amount of the manufacturers’ coupons.

Insurers sometimes offer the programs to consumers under euphemistic names like “Employee Savings Program” that sound good in theory, but, in reality, take away some of the value of the coupons, Long said.

Initially, consumers will see savings at the pharmacy counter, but they may end up paying more in the long run.

5. What if you’re on Medicaid or Medicare?

Medicare and Medicaid beneficiaries are prohibited from using manufacturer-sponsored coupons.

A federal anti-kickback law makes it illegal to give someone anything of value to influence their decision to purchase something that will ultimately be paid for by a federal health care program. The law also prevents remuneration, which includes waiving copays and charging less than fair-market value for a product.

Manufacturer drug coupons categories.

Some states, notably California and Massachusetts, prohibit or limit the use of manufacturer drug coupons when a generic version of the drug is available — highlighting the tension among manufacturers, health plans, and the government.

This <a target="_blank" href="/health-care-costs/pharmacy-discount-coupons-hidden-costs/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

No surprise. About are “worried about being able to afford prescription drug costs for themselves or their families,” a recent KFF nationwide poll showed. More than 80% consider the price of prescription drugs “unreasonable,” and most support increased regulation to lower costs. Americans pay about three times as much as people in other countries for the same prescription drugs.

Last July, Trump sent letters to 17 drugmakers, demanding they voluntarily lower drug prices. Then the president said he’d negotiated one by one at the White House. In December, that he had compelled them to agree to on Medicaid, the government coverage for low-income Americans.

Then came the , a site where cash-paying patients could find discounted medicines, and a promise to speed biosimilar products — generic versions of certain high-priced specialty drugs — by cutting through FDA red tape.

The scope of these grand gestures remains uncertain. But it’s certainly less than what the announcement promised, partly because many details of the negotiations, even which drugs are covered, are hazy.

White House spokesperson Kush Desai did not answer queries about TrumpRx.

Medicaid already buys drugs at deep discounts. And other patients may well have better options through commercial drug discount programs, which offer far more products, or through their insurance and associated drug company copayment cards.

So, for all Trump’s showmanship, the share of Americans likely to benefit from these options remains slim, even if some people do come out ahead.

“If it makes a difference to any patient, it’s a win,” said Mark Cuban, a billionaire investor on his own mission to bring down drug prices. He pointed to discounted pricing on TrumpRx for branded fertility drugs and GLP-1 weight loss drugs for people without insurance or whose plans don’t include coverage. Cuban launched the Mark Cuban Cost Plus Drug Co., known as Cost Plus Drugs, in 2022 to sell drugs cheaply by eliminating middlemen — buying from factories and selling directly to consumers. Most of the drugs he sells are generics.

Aaron Kesselheim, a professor of medicine at Harvard Medical School whose research focuses on drug prices, said the Trump announcements are “one-off agreements made for publicity purposes. They don’t change anything about the way drugs are priced.”

He added: “The agreements are opaque and unenforceable.”

It was unclear, for example, which drugs would be sold at “most favored nation” prices or how exactly that was defined. But, clearly, not all were.

Doing the Math

46brooklyn, a consulting firm and data project that tracks brand-name drug prices, found that close to 1,000 brand drugs went up in price in January 2026. What’s more, 2025 had the highest number of list price increases ever. “This is not a material change, it’s business as usual,” said Antonio Ciaccia, the company’s co-founder.

In the first week of 2026, Pfizer raised the list prices of 71 drugs by an average of 5% and lowered the price of only one, by 9.8%, the data project found.

The biggest win for patients has likely been the Trump administration’s quiet continuation of a Biden administration program: Medicare drug price negotiation for expensive drugs. The negotiated discounts on the — from blood thinners to insulins to medicines for inflammatory disorders — went into effect Jan. 1. With reductions in price of on some products, the estimated $6 billion in annual savings allowed the program to cap Medicare patients’ out-of-pocket spending on Part D prescription drugs at $2,000 for 2025 and beyond.

An additional 15 high-priced drugs — including popular weight loss and cancer drugs — were subject to negotiation in 2025, with discounted Medicare prices taking effect next year. And 15 more high-priced drugs are . All told, the 40 negotiated drug prices are expected to save Medicare well over $20 billion a year.

Even as these discounts take effect, drug industry lobbyists have been working to limit the impact, with some success. For example, the One Big Beautiful Bill Act from negotiations.

Still, “this is historic because it’s the first time the United States has negotiated prices, like every other developed country,” Kesselheim said. “And guess what? Innovation didn’t stop.”

Of course, these discounts benefit only Medicare enrollees. The newer Trump administration initiatives help some other patients, but they are limited and require knowledge of how to access the discounts.

Trump’s One-on-Ones

The president’s televised appearances with the heads of major drug companies resulted in deals, but few, if any, will mean much to patients. For example, after Trump met with Albert Bourla, CEO of Pfizer, the company announced discounts on 30-plus drugs. Bourla “a win for American patients, a win for American leadership, and a win for Pfizer.”

The discounts are offered via TrumpRx, which, in turn, offer coupons co-branded on GoodRx.com, which already offers discount coupons for many hundreds of medicines.

Pfizer made hay of the deal, announcing it was part of Pfizer’s broader, landmark with the U.S. government, enabling patients to pay lower prices for their prescription medicines “while strengthening America’s role as the global leader in biopharmaceutical innovation.”

Pfizer spokesperson Steven Danehy cited a press release from September noting that the TrumpRx site offers patients savings that “range as high as 85%.”

Most of the list features brand-name drugs, competing with far cheaper generic versions from other manufacturers, such as the cholesterol-lowering drug Colestid, which TrumpRx lists for “50% off” at $127.91. Generic versions cost about $17 on the Cost Plus site.

This means the branded companies aren’t making a sacrifice by offering them at lower costs as reflected on Trump’s portal, said Sean Tu, a patent law expert at the University of Alabama. “That’s a sale they would not have made if not for TrumpRx.”

Others are very old drugs, such as Cortef, or hydrocortisone, whose 5-milligram branded Pfizer version is listed at $45 on TrumpRx, half its list price of $91.80. It sells for far less on Cuban’s Cost Plus site. Still others, such as the $607.20 HIV treatment Viracept, are useful only in combination with other drugs that are not discounted.

Last week, TrumpRx added AbbVie’s Humira, for years the world’s best-selling drug, at $950 a dose, down from a list price of nearly $7,000. But Humira lost its patent protection in 2023, and biosimilars — essentially generic equivalents — have since come to market. More to the point, two of those biosimilars are listed on TrumpRx for as little as $207.60 a dose.

Since most of the TrumpRx products are available only to customers without insurance who pay cash, the arthritis drug Xeljanz’s drop from $2,277 to $1,518 a month would still leave it unaffordable.

A Few Notable Deals

The much-touted TrumpRx site, launched Feb. 6, consists largely of Pfizer’s 30 drugs (30 of roughly 85) with a smattering of discounts likely to generate headlines.

These include three fertility drugs from EMD Serono, a subsidiary of the pharmaceutical giant Merck KGaA, the most expensive of which, Gonal-F, has a list price of $966 but is only $168 per IVF cycle using a TrumpRx coupon.

They will save women thousands of dollars — although the overall cost of fertility treatment will continue to put them beyond the reach of many, since drugs represent only a portion of the payment.

The TrumpRx discounts could reduce the $15,000-to-$25,000 cost of a single fertility treatment cycle — women typically need two or three cycles to become pregnant — by about 10%, said Sean Tipton, spokesperson for the American Society for Reproductive Medicine. In some European countries, each cycle costs about $3,000.

In exchange for lowering those prices, EMD Serono got tariffs lifted on its mostly overseas-produced medications. It also won the right to a sped-up FDA approval process for a fertility drug it’s been marketing heavily in Europe.

Another newsworthy offering on the site resulted from a deal with Novo Nordisk for Wegovy, its GLP-1 drug for weight loss and diabetes, with the price reduced to as little as $199 a month for the pen. (Many insurers cover such drugs only for diabetes, leaving those who are interested in losing weight paying out-of-pocket. Zepbound, Wegovy’s Lilly & Co. competitor, is also on the list, at $299.)

Pressure has been building on Novo and Lilly to lower the U.S. price of their GLP-1 drugs. The compounds have lost patent protection in India, and pressure from customers buying overseas will likely increase when generic Wegovy goes on sale in Canada, for as low as $73 a month, possibly this year.

In the United States, meanwhile, dozens of patents should keep Wegovy generics off the market until 2039, said professor Robin Feldman, a patent expert at the University of California Law-San Francisco. A from the research group I-Mak delved into several ways patent manipulation keeps generics off the U.S. market long after they are available in European countries and Canada.

And while the Trump administration has vowed to approve biosimilars more rapidly to ensure more competition and lower prices, that may not have much impact. The big hurdle in getting generics and biosimilars to market is often not FDA approval, but the time it takes to override the thickets of patents that U.S. law allows manufacturers to deploy to protect their intellectual property.

For example, in 2021, the FDA approved a generic of Otezla, a popular drug for psoriatic arthritis, but it will not hit the market until 2028. Its entry would to Medicare if they charged the program more than other developed countries for “single source” drugs and biologics. That would essentially allow the Medicare program to piggyback on other countries that negotiate the prices of some of the most expensive medicines. Those programs are still going through the rulemaking process and, again, would benefit only those covered by the Medicare program and only indirectly.

The average patient-consumer, if willing to pay cash, may find some bargains. But getting the best deal could take a lot of mixing and matching, forcing patients to become choosy shoppers, eyeing deals for essential medicines as they would for a carton of milk or eggs.

Data reporter Maia Rosenfeld contributed to this article.

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