The Preserving Patient Access Act requires Medicare and individual market plans to notify enrollees of mid-year provider or prescription changes and establishes special enrollment periods for those affected.
Jacky Rosen
Senator
NV
The Preserving Patient Access Act protects consumers by requiring Medicare Advantage plans to notify enrollees when their providers leave a network and by restricting mid-year prescription drug coverage cuts. Additionally, the bill mandates that individual market health plans offer special enrollment periods to patients affected by these mid-year network or formulary changes. These measures ensure patients maintain consistent access to their preferred doctors and necessary medications throughout the plan year.
New Healthcare Bill Grants Special Enrollment Rights for Mid-Year Doctor and Drug Coverage Changes Starting 2027
The Preserving Patient Access Act aims to stop insurance companies from pulling the rug out from under you in the middle of the year. Starting January 1, 2027, this bill requires Medicare Advantage plans to proactively notify you if a doctor you’ve seen in the last two years—including via telehealth—drops out of their network. It also puts a leash on Medicare Part D plans, preventing them from making 'negative formulary changes' to drugs you’ve been prescribed in the last six months, provided those meds are still FDA-approved. Essentially, if you picked a plan specifically because it covered your specialist or your maintenance medication, the plan can’t change the rules halfway through the year without giving you a way out.
Breaking the Mid-Year Lock-In
Currently, if your favorite doctor leaves your insurance network in July, you’re often stuck paying out-of-network rates or finding a new provider until the next open enrollment period. Under this bill, the individual market gets a major upgrade in flexibility. Section 2702(b)(2) of the Public Health Service Act would be amended to create a new 'Special Enrollment Period.' This means if your provider leaves the network or your plan stops covering a drug you’ve used in the last six months, you don’t have to wait until January to switch. You gain a window to jump to a different plan that actually meets your medical needs, and the health insurance exchanges are required to update their systems to let you do it.
Real-World Relief for Patients
Think of a freelance graphic designer who specifically chose an individual plan because it included the local oncologist treating their remission follow-ups. If that oncologist and the insurer have a contract dispute in May and part ways, the designer would no longer be trapped in a plan that doesn't cover their doctor. Similarly, for a senior on Medicare Part D who relies on a specific brand-name medication, this bill ensures that if they’ve had that drug dispensed in the last six months, the plan can’t suddenly hike the price or drop coverage mid-year. It’s about ensuring that the 'deal' you signed up for during open enrollment stays the same for the full twelve months.
Implementation and Accountability
While the bill is clear on the 'what,' the 'how' involves a significant tech lift for insurance exchanges. Section 1311 of the Affordable Care Act would be updated to ensure that the digital marketplaces can process these specific life events. This isn't just a suggestion; it’s a mandate for the systems to recognize these network and drug changes as valid reasons to switch coverage. Because the bill targets changes to the Social Security Act and the Public Health Service Act, it creates a uniform standard across both federal Medicare programs and the private individual market, providing a safety net for everyone from retirees to self-employed contractors.