"[The Consolidated Appropriations Act, 2026 includes] significant disclosure requirements applicable to pharmacy benefit managers (PBMs) -- effective 30 months following the enactment of the legislation -- and the requirement for ALL service providers to group health plans to disclose all direct and indirect compensation they receive in connection with the plan, effective for contracts entered into or renewed after the effective date of the CAA 2026. These new rules will have a significant impact on the contracting process for all group health plan contracts." MORE >>
"Key developments include: [1] PBMs treated as 'covered service providers' for purposes of [ERISA] Section 408(b)(2) subject to compensation disclosure requirements. [2] Required 100% rebate and remuneration pass through to ERISA plans, with limited exceptions ... [3] Mandatory semiannual reporting of detailed drug pricing, spread pricing, rebate, and compensation data to group health plans. [4] Civil penalties for noncompliance. [5] A limited 'innocent fiduciary' exception for plan fiduciaries under specified conditions." MORE >>
15 pages. "[CMS] released the 2027 Advance Notice, which details planned changes to the Part C and Part D capitation and risk adjustment methodology for calendar year (CY) 2027. The growth rate and risk model changes together resulted in a substantially lower estimated benchmark trend than the industry was expecting.... [B]ased on experience with benefit reductions that took place in 2026, Wakely estimates that the Advance Notice could lead to a projected 15% decline in average plan rebate dollars from 2026 to 2027." MORE >>
"Plaintiffs' firms have begun applying the excessive fee playbook to health plans ... At the same time, group health plans remain under scrutiny from the [DOL].... In the current regulatory enforcement and litigation environment, revisiting fiduciary governance practices, particularly around service provider selection, fee monitoring, and oversight, can reduce exposure and strengthen overall fiduciary compliance." MORE >>
"plan fiduciaries will need to promptly ... [1] Create an inventory of existing service providers and vendors to their ERISA covered health plans ... [2] Determine if appropriate fee disclosures have been obtained from such vendors/service providers; [3] If [not], request them from the vendors/service providers; [4] Once obtained, review the fee disclosures and service relationships ... [5] If a vendor/service provider does not respond to requests for fee required disclosures, consider next steps, which could involve terminating the relationship and reporting the vendor to the DOL. [6] Keep a record of fulfilling these fiduciary functions." MORE >>
"[1] Innovative new plan designs ... [2] A resurgence of high-deductible health plans ... [3] Use of an integrated benefits platform ... [4] Biosimilars gaining traction ... [5] Continuing pediatric mental health cost challenges." MORE >>
"This brief examines two measures of financial performance -- gross margins and medical loss ratios -- in the Medicare Advantage, Medicaid managed care, individual, and fully insured group health insurance markets ... At the end of 2024 ... [g]ross margins per enrollee in the group market was $846, roughly half the level observed among Medicare Advantage plans on average. Per enrollee gross margins in the individual market in 2024 amounted to $987." MORE >>
"[E]mployers expect their healthcare costs to increase an average of 10% for 2026, after accounting for changes to their plan offerings (including plan design changes and types of plans being offered). If no changes were made to plan offerings, employers would have expected an increase of 12%." MORE >>
"As organizations representing employers, workers, patients, consumers, and brokers we write to express growing concern that the current operation of the Independent Dispute Resolution (IDR) process under the No Surprises Act (NSA) is undermining affordability and weakening protections for the millions of Americans who rely on job-based health insurance. The NSA was designed to prevent surprise medical bills and promote fair negotiation, but the IDR process is increasingly being used in ways that raise costs for patients, plan sponsors, health plans, and the broader health care system." MORE >>
12 pages. "The notice includes important proposed rules and parameters for the operation of the individual and small group health insurance markets in 2026 and beyond. This paper summarizes key provisions in the proposed notice and maximum out-of-pocket cost information recently released by HHS. Comments are due no later than March 13, 2026." MORE >>
"This report describes current law and applicable regulations and guidance, specifically with regard to how the PTC and CSR requirements apply in 2026." [R44425 Feb. 19, 2026] MORE >>
14 pages. "[ERIC recommends] that the Departments require the CEO or authorized representative of the owner of the provider network to 'attest' that any TiC MRF produced by this provider network owner is complete and accurate and in compliance with the TiC regulatory requirements.... [If] the owner of the provider network produces a TiC MRF that is non-compliant, the liability for such non-compliance should not rest with the plan sponsor, but instead any liability should rest with the entity that is producing the TiC MRFs in the first place." MORE >>
"CGT users represent fewer than 0.1% of the enrollee population but account for approximately 0.5% of total spending. This includes both the cost of CGTs and spending on other health services.... Impact on High-Cost Claimants: Among enrollees in the top 1% of total health care spenders, just 0.58% used CGTs. However, these individuals accounted for 1.6% of spending within that top spending group. While the share is small, it signals that CGTs can meaningfully impact spending patterns among high-cost claimants." MORE >>
"The average plan could pay for approximately one year and four months of benefits and expenses with its net assets, an increase of approximately one-and-a-half months of total expenses from last year.... On a per member basis, expenses increased by 5.8% and total contribution income increased by 3.2% year over year. Over 80% of plans had a net gain in 2023, a significant improvement compared to both 2021 and 2022, when plan income was greater than expenses for about half of plans." MORE >>
"This third report extends trends in claims data in this series into 2022, the first year post-NSA implementation.... In 2023, providers won around 80% of IDR determinations over OON claims and around 85% of IDR determinations over OON air ambulance services. This report also includes an analysis of trends in consolidation in health care markets, though it does not attempt to estimate specific effects of the NSA." MORE >>
"[T]he HHS Notice of Benefit and Payment Parameters ... establishes the indexed out-of-pocket maximum limits that apply to non-grandfathered group health plans beginning on or after January 1, 2027. Group health plan sponsors should evaluate these updated limits when finalizing plan designs for 2027, specifically regarding whether to increase out-of-pocket maximums or leave them unchanged." MORE >>
"One of the most thorough analyses of the quality of hospital and health plan price transparency data got little attention when it was published last fall.... [T]he 185-page report from the Purchaser Business Group on Health (PBGH) ... shows the problems employers face when contracting with health insurers and hospitals for workers' health coverage." MORE >>
"Among specialties likely to be affected by the No Surprises Act protections -- emergency medicine, radiology, anesthesiology, and air ambulance -- the percentage of in-network claims increased for three of the four specialties after the act took effect.... Payment changes for the selected services largely reflected continuations of trends prior to the No Surprises Act taking effect." [GAO-107169 Feb. 19, 2026] MORE >>
68 pages. "What's New: [1] Changes to 'coverage month' definition for PTC/ APTC.... [2] Reporting entities no longer required to send minimum essential coverage (MEC) forms automatically." MORE >>
"The Consolidated Appropriations Act (CAA) 2026 expands the compensation disclosure requirements under ERISA to require ERISA-covered group health plans to receive compensation disclosures from nearly all of their plan vendors ... The provision appears to be effective immediately and is likely applicable to contracts entered into or renewed between a plan and a service provider after the date of enactment (i.e., after February 3, 2026). Employers who are in the process of selecting a new service provider for their group health plan, including renewing, or extending the contract of an existing provider, should review the requirements and request the appropriate compensation disclosures from service providers." MORE >>
"Plan fiduciaries would be responsible for ensuring that they receive required disclosures. They would also be responsible for the reviewing the disclosures to determine whether any actions need to be taken in response to the disclosures, such as exercising their right to audit the accuracy of the disclosure." MORE >>
"Recently, the 2026 federal poverty level (FPL) was announced as $15,960 (up from $15,650 in 2025).... [E]mployers may use the federal poverty guidelines in effect six months before the start of the plan year when applying the FPL safe harbor." MORE >>
"Settlor decisions about premium-setting may offer a structural litigation defense. When premiums do not directly correlate to plan cost experience, plaintiffs have difficulty showing that alleged PBM overcharges increased their out-of-pocket costs.... If plan fiduciaries have determined that engagement or retention of a vertically-integrated PBM is prudent despite the potential conflicts of interest, plan sponsor/settlor decisions about plan design may help mitigate those conflicts." [Lewandowski v. Johnson & Johnson, No. 24-0671 (D.N.J. Nov. 26, 2025)] MORE >>
"This article addresses several proposed changes to the regulation and sale of catastrophic plans, ... new policies to implement parts of the OBBBA ... new cost-sharing reduction (CSR) reporting requirements; and old policies that were adopted in last year's marketplace rule but set aside in court (including pre-enrollment SEP verification requirements and income verification requirements)." MORE >>
"This article addresses the proposed rule's changes to essential health benefits (EHB) requirements, standardized plans, network adequacy, essential community providers (ECPs), and risk adjustment. It also discusses HHS requests for information on premium payment thresholds and medical loss ratio (MLR) standards." MORE >>
