"One change that could increase traffic in the IDR portal is a reduction in the administrative fee for IDR participants from $115 to $15 per case.... Although slashing the fee could further increase the number of IDR cases, the federal departments say other finalized provisions should counter that trend.... Payers face new claim communication requirements ... Open negotiation becomes a more structured step ... Batching rules and eligibility reviews will shape dispute volume ... IDR eligibility scrutiny is set to increase ... Payer identification should become easier" MORE >>
"Beginning with the 2027 plan year, insurers will no longer be required to offer standardized plans ... HHS now believes that these plans are 'an ineffective strategy' to simplify the plan selection process, improve the consumer experience, and increase consumer understanding.... The final rule permanently removes the option for insurers to use fixed-dollar and gross-premium threshold flexibilities beginning with the 2027 plan year.... [T]he final rule will largely continue current risk adjustment policies, with narrow exceptions.... The final rule adopts a [risk adjustment] user fee rate of $0.18 per member per month for the 2027 benefit year, a slight decline from the $0.20 per member per month fee that applied for the 2026 benefit year." MORE >>
"This decision adds to a growing split on whether providers may enforce IDR awards through private litigation. While the Fifth Circuit has held that no such right exists, this court and certain other federal trial courts have concluded otherwise, meaning that plans and insurers operating outside the Fifth Circuit may face greater exposure to enforcement lawsuits when they fail to pay IDR awards within the required 30-day window." [PHI Health, LLC v. Optimum Choice, Inc., No. 25-2320 (D. Md. Mar. 27, 2026)] MORE >>
607 pages. "This document sets forth these final rules related to certain provisions of the No Surprises Act regarding the Federal independent dispute resolution (IDR) process, which was established as part of the Consolidated Appropriations Act, 2021 (CAA). These rules finalize new requirements relating to the disclosure of information that group health plans and health insurance issuers offering group or individual health insurance coverage must include along with the initial payment or notice of denial of payment for certain items and services subject to the surprise billing protections in the No Surprises Act. These final rules also require plans and issuers to communicate information by using claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs), as specified in guidance, when providing any paper or electronic remittance advice (ERA) to an entity that does not have a contractual relationship with the plan or issuer. This document also finalizes amendments to certain requirements related to the open negotiation period preceding the Federal IDR process, the initiation of the Federal IDR process, the Federal IDR dispute eligibility review process, and the payment and collection of administrative fees and certified IDR entity fees. This document also finalizes the definition of bundled payment arrangements, amends requirements related to batched items and services and amends the rules for extensions of timeframes due to extenuating circumstances. Additionally, this document finalizes provisions that require plans and issuers to register in the Federal IDR portal." MORE >>
"These final rules will improve the functioning of the Federal IDR process by streamlining communication between payers, providers, and certified IDR entities and clarifying timelines and processes.... [T]he Departments are finalizing a requirement for payers to communicate information to providers by using specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) when they provide any paper or electronic remittance advice to an entity that does not have a contractual relationship with the payer.... [T]he Departments are finalizing several changes to the open negotiation requirements.... the Departments are finalizing a few amendments to the current batching provisions.... The Departments are also finalizing a revision to the types of extenuating circumstances in which the Federal IDR process time periods may be extended.... The requirement that payers communicate information using CARCs and RARCs and the modifications to the regulations addressing information to be shared about the QPA will take effect on the effective date of the final rules." MORE >>
"Oregon Potato claims that Marsh violated [ERISA] by using a consulting firm ... to manage the company's health plan.... According to [the lawsuit, the defendants] recommended in 2023 that the company switch from a fully insured health plan to a guaranteed level-funded premium plan. The arrangement allegedly enabled [the consulting firm] to collect excessive fees and disadvantaged plan participants, who failed to receive medical benefits for the guaranteed premiums they paid." [Oregon Potato Co. v. Strong, No. 25-5139 (E.D. Wash. Mar. 2, 2026)] MORE >>
"For many employers, there's no clear fix to the spending surge. Traditional plan options to lower expenses have netted only limited benefits. High-deductible health plans push the cost to the employee; wellness programs have low uptake and little data supporting their efficacy; value-based care is difficult to implement; and pharmacy costs continue to rise even with the growth of transparent pharmacy benefit managers (PBMs).... The challenge is implementing changes that fit into the employer's culture so that employees embrace the new approach." MORE >>
10 pages. "Simply matching prior fully insured premiums rarely reflects the true cost structure of a self- funded plan. Claims volatility introduces both risk and opportunity. Favorable experience can generate surplus and long-term savings, whereas adverse experience can create short-term funding pressure. Establishing an appropriate funding margin and surplus policy helps stabilize results and ensure the plan's financial sustainability across multiple years." MORE >>
"Federal courts are seeing a new wave of Employee Retirement Income Security Act (ERISA) suits based on university health plans that allegedly directed plan participants toward university-affiliated providers without appropriate transparency. Current litigation is pending involving Northwestern University and the University of Rochester, both of which utilize tiered network arrangements. According to the plaintiffs' claims, these arrangements result in much higher costs for plan participants who seek care outside the preferred affiliated network." MORE >>
"Health insurers facing growing criticism over rising premiums are trying to shift the narrative by portraying hospitals and drugmakers as the real culprits behind health care's affordability crisis.... Insurers and employer-backed advocacy groups ... are running ads pointing out hospitals' outsized presence in some markets, with messages like 'hospital monopolies put profits over patients.' " MORE >>
"Based on large-employer survey data, 79% were surprised by rate increases, and 94% have experimented with alternative cost-containment approaches. Brokers have said average savings for clients that switch to ICHRAs are 15.5%, but the cost savings may not be the only argument." MORE >>
"Congress' decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance ... Unlike plans sold on the exchanges, these options -- some sold by major insurers, others by small companies or nonprofits -- can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover 'essential health benefits,' such as preventive care, and can impose annual or lifetime caps on benefits. There is debate over whether these options help or harm patients." MORE >>
"The U.S. House Committee on Education and the Workforce on May 21 advanced a series of bills prohibiting pharmacy benefit managers from providing kickbacks or referral fees to intermediaries [HR 7895], requiring hospitals to adopt accurate billing practices [HR 8684], and extending the deadline for plans to file Form 5500 disclosures [HR 7362]. The bills, each affecting plans governed by [ERISA], may now receive consideration from the full House of Representatives." MORE >>
"56% of brokers are now recommending the program as an option. The number of brokers who said they moved at least one client to an ICHRA plan reached 37% in 2026, increasing from 15% in 2024." MORE >>
"Congress created the federal independent dispute resolution process (IDR)to determine payment when providers and insurers cannot agree. In theory, IDR was designed to be a streamlined arbitration process. In practice, it has experienced significant disputes and challenges within the healthcare reimbursement landscape, even though many providers still do not appreciate the legal and financial risks the process can entail." MORE >>
"[D]irect primary care practices grew from 3% to 9% of family physicians between 2022 and 2023. Employees pay a monthly fee directly to the doctor, bypassing insurance entirely for routine care. The market is projected to grow from $60 billion in 2025 to $92 billion by 2035.... Employer groups with direct primary care spend roughly 52% less than groups without it. When insurance billing complexity for routine care is eliminated, overhead drops and costs follow." MORE >>
"Between 2025 and 2026, we estimate that employer-sponsored healthcare costs will grow by 7.9%, from $7,838 to $8,460 for the average person.... Outpatient facility care and pharmacy services are the primary drivers of cost increases in 2026, contributing to 69% of the year-over-year rise.... Enter your location and family characteristics ... to estimate your total 2026 healthcare costs, including the portion of your healthcare spending that will go to your premium, doctor visits, out-of-pocket expenses, and prescriptions." MORE >>
"[T]he median percentage remaining in 2022 after medical OOP spending was 71 percent for Social Security benefits and 88 percent for total income. ... In other words, OOP takes a big chuck of retirees’ resources, and the 10-percent increase in Medicare Part B premium [in 2026] suggests no relief on the horizon." MORE >>
"While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is in Georgia, which saw a 28% drop in April compared with the same period a year ago ... The initial results come amid rising public concern about affordability[.]" MORE >>
"For decades, the standard insurance carriers have ... convinced self funded employers that without a legacy PPO network, their plans would collapse into a chaotic mess of balance bills and member disruption.... But the landscape of commercial health insurance just shifted permanently in Indiana. The Hoosier state has done something entirely new, and it provides an exquisite blueprint for how forward thinking employers can completely eliminate the legacy carrier network once and for all." MORE >>
1121 pages. "This final rule contains provisions to improve implementation of the [ACA], including payment parameters and provisions related to the HHS-operated risk adjustment and risk adjustment data validation (HHS-RADV) programs, as well as 2027 user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal platform (SBE-FPs). This final rule also includes [1] provisions related to civil money penalties (CMPs) for noncompliant issuers and other responsible entities; [2] standards governing agents, brokers, and web-brokers; [3] the expansion and codification of hardship exemption eligibility; [4] implementation of the State Exchange Improper Payment Measurement (SEIPM); [5] provider access standards and essential community provider standards for QHP certification; [6] QHP certification of non-network plans; [7] a prohibition on issuers from including routine non-pediatric dental services as an Essential Health Benefit (EHB); [8] requirements related to defrayal for the cost of any State-required benefits in addition to the EHB; [9] cost-sharing flexibilities for catastrophic and individual market bronze plans; [10] establishment of catastrophic plans with plan terms of up to 10 consecutive plan years; [11] QHP issuer quality improvement strategies (QISs); and [12] revisions affecting which enrollees are included in Federal Basic Health Program (BHP) payment calculations to States. This final rule also includes amendments to implement certain provisions of the Working Families Tax Cut (WFTC) legislation." MORE >>
"The final rule ... reduces federal Exchange user fees to help lower premiums, establishes new safeguards to prevent improper enrollments, ensures subsidies go only to eligible individuals, increases consumer choice, affordability, access and protections, and expands state flexibility to manage Exchange operations. The rule strengthens program integrity, expands consumer protections, promotes plan innovation and consumer choice, and restores greater authority to states." MORE >>
"Many health plans already include in-network virtual providers without requiring additional employer contracts or fees. Virtual care can improve access to specialty services, reduce delays, and support employee engagement in care. Employees may not realize virtual providers are covered through their health insurance network. Employers can increase utilization through proactive communication and collaboration with health plans." MORE >>
36 pages. "[E]mployers can influence behavior change to better manage health care costs and employee well-being. Claims-based insights and personalized guidance can help -- especially amid rising expenses, inflation pressures, growing mental health needs and a shifting policy landscape.... [This report provides] data-backed insights on the main drivers of rising benefits costs, how to optimize investments, patterns in employee decision-making and emerging solutions that create value for employers and employees." MORE >>
"An analysis of health plan data ... looked at members with claims in excess of $100k per year. While they accounted for just 1% of the 2.3 million members in the analysis, they drove 34% of total employer healthcare spend in 2025.... [A]reas where focused efforts can help employers rein in costs. [1] Understand your data: Analyzing claims to gain clarity.... [2] Strategic oversight of medical specialty pharmacy and gene/cell therapies.... [3] Take a peekaboo view into neonatal intensive care unit management.... [4] Outlier inpatient stays." MORE >>
