2025 Legislative Landscape: States Tackle Health Costs, Coverage and Delivery

Key Takeaways

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State legislatures are addressing a wide range of issues related to access and affordability in commercial health plans. These issues include coverage, network adequacy, payment and delivery reforms, individual marketplaces, medical debt and surprise billing, health insurance alternatives, and price transparency.

In 2025, 48 states, Puerto Rico, the Virgin Islands and Washington D.C. enacted at least 449 bills focused on health care costs, coverage and delivery within commercial markets.

Health Insurance Coverage and Network Adequacy

States enacted at least 213 bills in 2025 related to insurance coverage or network adequacy.

Health insurance mandates often require state-regulated health plans to cover specific benefits or certain providers. Legislation mandating coverage for certain types of screenings, including genetic screenings, continues to emerge as a theme across legislatures. This past session, Arkansas mandated genetic testing coverage and evidence-based cancer screenings for certain individuals and Nevada required coverage of certain fetal screenings for genetic disorders. Additionally, states like Virginia and Alabama have enacted coverage mandates for screenings for specific types of cancers. As states grapple with rising health care costs, several states have enacted or updated legislation requiring cost studies on new or existing state health insurance mandates, including Connecticut, Louisiana, Minnesota and North Dakota.

Network adequacy refers to standards that insurers must follow as they contract with providers to establish their networks, including requirements for certain numbers and types of in-network providers, distance to providers and appointment wait times. Illinois enacted legislation requiring its Department of Insurance to consider establishing minimum ratios of plan enrollees to genetic medicine and genetic counseling providers. Oregon required its Department of Consumer and Business Services to establish rules for evaluating insurers' provider networks, including standards for geographic access and appointment wait times. Florida mandated that the biennial audits of its behavioral health managing entities must include audits on provider network adequacy and participation in certain data submissions.

Medical Debt and Surprise Billing

With more than one-third of U.S. households reporting some form of medical debt, state policymakers are exploring proactive strategies to reduce the likelihood of patients receiving unaffordable medical bills and to strengthen protections for individuals already burdened by medical debt. In 2025, at least 40 bills related to medical debt and surprise billing were enacted across 22 states, reflecting a wide-ranging set of policy approaches.

States took a variety of actions to address medical debt, including using state appropriations to pay off residents' medical debt, curbing specific types of collection practices, limiting the sale of medical debt, capping interest rates and regulating how medical debt is reported to consumer credit agencies. For example, Maine prohibits the reporting of medical debt on consumer credit reports. New Hampshire allows individuals to claim the full value of their property as a homestead exemption when their debt is from unpaid medical bills or from a serious or terminal illness or injury.

Recognizing that unexpected medical bills can contribute to medical debt, states have also pursued a range of policy responses related to surprise billing. Arizona enacted legislation requiring the Department of Insurance and Financial Institutions to issue a standard notice outlining enrollee rights and the dispute process for surprise out-of-network bills. Oregon now prohibits ground ambulance providers from balance-billing patients and requires insurers to reimburse those services at locally established rates or at least 325% of the Medicare rate.

Price Transparency

In response to rising health care costs and what some consider to be opaque pricing practices, several states have enacted legislation to improve consumer and regulatory access to information about the cost of health care services. These efforts are often designed to support consumer decision-making and encourage market competition by making pricing data more readily available. Although research indicates that price transparency alone may have a modest effect on consumer choices, such initiatives can provide a foundation for broader cost-containment strategies and may be paired with complementary approaches, such as patient financial incentives or quality information.

Recent state legislation reflects a growing emphasis on compliance and enforcement mechanisms tied to price transparency. For example, Nevada now requires hospitals to publish detailed pricing lists for services and prohibits certain debt collection practices if a hospital is out of compliance. Similarly, Oklahoma enacted legislation requiring hospitals to publish all standard charges and a consumer-friendly list of "shoppable" services; if a hospital fails to comply, the law bars debt collection and requires removal of related credit report entries.

Health Insurance Alternatives

On average, health insurers have proposed an 18% increase in individual market premiums nationally in 2026 due in part to rising health care costs and federal policy changes, including the scheduled expiration of enhanced premium tax credits.

To address affordability and encourage flexibility in coverage, states continue to explore policies related to alternative health insurance coverage options, such as association health plans, short-term limited duration health insurance, health care sharing ministries or direct primary care arrangements. While these coverage options typically have lower monthly premiums, they often do not have to comply with certain state insurance laws and consumer protection provisions established by the Affordable Care Act. At least 15 states enacted at least 19 bills in 2025 related to these alternatives.

Ohio and Missouri enacted legislation creating guidelines for health plans offered by nonprofit agricultural membership organizations, also known as Farm Bureau Health Plans, and other qualified membership organizations. North Dakota specified that a student's participation in a health care sharing ministry satisfies any institution of higher education's requirements for health care coverage.

Health Insurance Marketplaces

In 2025, policymakers considered legislation affecting consumer access and affordability for the Affordable Care Act marketplace plans. Ongoing federal policy shifts to the marketplaces - including changes to automatic re-enrollment and shifting eligibility requirements, combined with the scheduled expiration of Enhanced Premium Tax Credits (EPTCs) are likely to affect health insurance coverage for about 24 million people.

At least 30 bills were enacted in 21 states in 2025 regarding health insurance marketplaces. Maryland created a State-Based Health Insurance Subsidies Program to provide subsidies to individuals on the marketplace to mitigate the impact of the possible reduction of EPTCs. New Mexico enacted legislation to provide state-based subsidies on its health care exchange for individuals meeting certain income requirements should the EPTCs expire. Oklahoma granted its Insurance Commissioner authority to apply for a Section 1332 State Innovation waiver and created a fund in the state treasury for the operation of Oklahoma's state-based marketplace exchange.

Health Care Payment and Delivery

States continue to explore ways to reshape health care payment and delivery systems through a range of approaches, with at least 88 bills enacted in 35 states.

Many states have implemented laws related to the prior authorization process, an approval obtained from a health insurer before certain services, procedures or medications are covered. In 2025, states such as Arkansas enacted legislation establishing "gold card" programs, which exempt certain providers from obtaining prior authorization. Other states including Alaska chose to require certain timelines for issuing prior authorization decisions, increased transparency in the appeals process after a claim was denied or mandated that insurers honor prior authorizations issued under a past health plan.

Value-based care and other payment reforms also saw legislative interest in 2025. Texas established requirements for insurer-provider contracts that contain value-based arrangements or capitated payment arrangements, which are fixed amounts of money paid to providers for each patient over a set period of time. Colorado revised its statute to require its Primary Care Payment Reform Collaborative to develop alternative payment models focused on pediatric primary care delivery. Florida required health facilities and providers to refund patients for any overpayment no later than 30 days after they discover an overpayment was made. Utah specified that health insurers must allow providers to opt out of receiving payment through a credit card through a single opt out process.

For more updates on legislative actions related to the commercial insurance market and other related topics, see NCSL's Health Care Costs, Coverage and Delivery Database.

For more information on legislative actions related to prescription drugs, see NCSL's Prescription Drug Legislation Database and Voters Want Affordable Meds. Legislatures Are On It.

This publication is supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The contents are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.