News Archive

"Outrageous provider-driven abuse of the No Surprises Act is adding billions in wasteful spending and raising healthcare costs for everyone. Policy action is needed to address flawed incentives in the IDR process and protect consumers from unconscionable price gouging by out-of-network providers and IDR middlemen[.]"  MORE >>

"ERISA cannot easily substitute for a coherent health care cost-containment strategy. It was not written to regulate provider markets, set prices, restructure incentives, or redesign the health care delivery system. Policymakers and advocates should therefore be careful not to ask ERISA to carry more than it can bear. The better course is to strengthen ERISA where it naturally applies -- transparency, fiduciary process, disclosure, and plan governance -- while addressing the underlying drivers of health care costs through other statutes and policies designed for that purpose."  MORE >>

"The Final Rule is effective August 3, 2026, with staggered applicability dates for specific provisions. The Final Rule represents the most comprehensive revision to the Federal IDR process since its establishment. Key Takeaways [1] Reduction in administrative fees ... [2] Comprehensive open negotiation reforms ... [3] Standardized communication codes ... [4] Revised batching rules and 50-item cap ... [5] New plan and issuer registration requirement."  MORE >>

"Absent a second income -- and physical support from a spouse or partner -- single retirees may: [1] Lack the economies of scale that are derived from shared expenses. [2] Allocate a larger percentage of their retirement income to health care costs. [3] Rely more heavily on paid long-term care services."  MORE >>

"As many employers are navigating higher 2026 HCSO payments, the increase in expenditure rates offers a timely opportunity for employers to review their HCSO compliance process. Failure to meet all compliance requirements using supportable methodology4 could result in investigation, corrective action, and penalties from the San Francisco Office of Labor Standards Enforcement."  MORE >>

"Provider networks were the most important factor when choosing a health plan, outranking premiums and other plan features.... Traditional plan enrollees placed greater importance on lower out-of-pocket costs when receiving care, while high-deductible plan enrollees placed greater importance on lower premiums. Prescription drug coverage increased in importance compared with prior years."  MORE >>

"By 2034, national health spending is projected to total nearly $9.0 trillion and to represent 20.6 percent of the economy, compared with $5.3 trillion and 18.0 percent in 2024. The rate of national health spending growth during this period is influenced by continued elevated use of medical services and goods through 2026; major legislative changes that affect insurance coverage and spending through 2028; and continued demographic shifts toward public programs, mainly Medicare. The insured share of the population is expected to be 90.5 percent in 2034, compared with 91.8 percent in 2024."  MORE >>

"The 2024 benefit year HHS-RADV error rates will be applied to 2024 benefit year plan liability risk scores and risk adjustment State transfers.... This memo contains a summary of the 2024 benefit year HHS- RADV results, and information to assist issuers in understanding their results.'

• National Program Benchmarks -- 2024 Benefit Year HHS-RADV (XLSX)
• 2024 Benefit Year RA State Market Risk Pool Weighted Average HHS-RADV Error Rates (XLSX)
• 2024 Benefit Year HHS-RADV Failure Rate Group Definitions (XLSX)
• 2024 Benefit Year HHS-RADV HCC Validation (XLSX)

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"One way to approach the challenge ... is to offer a lifestyle spending account (LSA) and add GLP-1 medication and support resources to the list of covered expenses. [Employers could also offer a] specialty care account benefit (SCA), dedicated specifically to areas like weight loss, hormone replacement, and mental health support.... SCAs are regulated because they are a healthcare benefit, and employers can offer up to $2,200 pretax ... Both of these benefit options allow employers to apply a fixed allowance toward selected health and wellness expenses, helping them establish cost predictability while enabling employees to spend funds on what they value most."  MORE >>

"Two-thirds of voters said that the federal government should make 'stop[ping] hospitals from charging excessive prices' their top priority -- more than any other policy proposal. Support for reining in hospitals' ever-higher prices is decisive across partisan and demographic lines ... Six in 10 voters said reining in surprise medical billing by providers should be a top priority -- the second-highest priority of all proposals tested."  MORE >>

"The [final rule] represents the most significant procedural overhaul of the IDR system since its launch in 2022, addressing the core dysfunctions that have plagued the process: an overwhelming volume of disputes, inconsistent eligibility screening, administrative fee structures that incentivized high-volume bulk filings, and a lack of standardized procedures. The rule aims to streamline the review process and enhance its auditability."  MORE >>

"In their opposition, Defendants argue that the eight challenged provisions of the 2027 NBPP final rule are authorized by the statute and are justified by current data and market conditions to address significant market failures. In addition, Defendants further contend that emergency relief is unwarranted because the Plaintiffs lack standing and have failed to demonstrate irreparable harm." [City of Columbus v. Kennedy ('Columbus II'), No. 26-2215 (D. Md. complaint filed Jun. 3, 2026)]  MORE >>

"Lewandowski, like its sibling PBM cases, failed at the standing stage. But beneath that procedural outcome lies a developing framework of expectations and potential risk pathways. The complaints can shape what stakeholders believe plan fiduciaries should be doing, so plan fiduciaries should treat these dismissals not as 'wins,' but as warnings. Overall, these cases should encourage plan fiduciaries to understand their PBM arrangements, question conflicts and compensation, consider proactive steps, and remain updated with news and litigation." [Lewandowski v. Johnson & Johnson, No. 24-0671 (D.N.J. Nov. 26, 2025)]  MORE >>

"Although many plan obligations are tied either to the calendar year or the plan year, there are two [ACA] items that arise 'off cycle' during the summer months: the Patient-Centered Outcomes Research Institute (PCORI) Fee and Medical Loss Ratio (MLR) rebates."  MORE >>

"Employers that are now receiving settlement proceeds should be aware that they may have fiduciary duties under ERISA with respect to the use of any proceeds from the settlement fund.... Unless specific guidance is issued related to the BCBSA settlement, employers may want to use the [the DOL's prior MLR guidance] as a reference when determining how to calculate what portion of the BCBSA settlement proceeds should be considered 'plan assets,' and how those funds can be used."  MORE >>

"[A] healthy 65-year-old couple retiring this year will need to save on average: [1] $418,000 under Original Medicare with Medigap Plan G plus Part D coverage, an increase of $30,000 (+7.7%) from 2025. The couple is projected to spend an average of $637,000 on healthcare expenses over the course of their remaining lifetime. [2] $211,000 with Medicare Advantage plus Part D (MAPD), an increase of $28,000 (+15.3%) from 2025. The couple is projected to spend an average of $320,000 on healthcare expenses over the course of their remaining lifetime."  MORE >>

"Employers are used to getting very little visibility from fully insured plans. When they're considering self-funding, they want to know that this time will be different. The answer ... [is] a combination of tools and capabilities working together: [1] Employer reporting that shows the financial picture. [2] Engagement and utilization data that reveals how the plan is being used. [3] Chronic care coordination that tracks how ongoing conditions are managed. [4] Patient outcome metrics that measure real health improvement. [5] Cost savings analysis that ties it all back to dollars."  MORE >>

"This essay collection examines how rising obesity prevalence affects future mortality, highlighting obesity-related diseases, severe obesity trends, weight-loss interventions, GLP-1 medications, alternative obesity measures, and actuarial implications for mortality forecasting, insurance pricing, underwriting, and public health planning."  MORE >>

"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 ... 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."  MORE >>

"Most employers are overpaying for healthcare by about $4,000 per employee each year, and the first step in reclaiming that lost profit is establishing proper governance and oversight. However, even the most robust fiduciary committee charter is only as effective as the adviser who guides it."  MORE >>

"The national median total cost for a C-section for commercially insured patients staying in network is $19,911 ... Alaska is the state with the highest median allowed amount for vaginal deliveries ... followed by (in order from highest to lowest) New Jersey, New York, Connecticut and Oregon. Alaska also has the highest median allowed amount for C-sections ... followed by Vermont, Maine, Oregon and Wyoming. Alabama has the lowest median allowed amount for vaginal deliveries ... [and] also has the lowest median allowed amount for C-sections[.]"  MORE >>

"The final policy may impact health plans that are not directly required to provide EHB, such as self-insured group health plans and large-group market fully insured plans that must follow the annual and lifetime dollar-limit restrictions on EHB and annual cost-sharing limitation requirements.... The final policy is consistent with CMS' desire to provide the 'regulatory framework' for innovation, without mandating it.... Issuers should plan to follow the timelines as outlined by their State and CMS. This policy is subject to litigation in Columbus II. "  MORE >>

"[The final rules] affect how a group health plan communicates with out-of-network providers, participates in payment negotiations, and resolves billing disputes. Because self-insured group health plans are ultimately responsible for ensuring compliance with these new IDR requirements, plan sponsors should work with their third-party administrator (TPA) to confirm that existing processes meet the new standards. Where gaps exist, plan sponsors may want to revise the TPA services agreement to address the requirements summarized below and consider including indemnification provisions or performance guarantees to protect the plan in the event the TPA fails to comply."  MORE >>

"The new rule reveals the administration's priorities, even as consumers' costs rise. It ratchets up scrutiny of the enrollment process and imposes administrative barriers it projects will cause up to 2 million people to lose coverage. At the same time, it relaxes standards for health insurers, greenlighting unprecedented flexibilities for companies to expose enrollees to massive out-of-pocket costs."  MORE >>

"[N]ew emerging 'dynamic copay' plans ... translate negotiated price variation into provider- and service-specific dollar copays displayed pre-service, often through app-based tools ... [The authors] examine the operational pre-requisites for 'copay integrity,' likely effects on out-of-pocket (OOP) predictability and spending in light of peer-reviewed evidence on tiered designs, and the constraints imposed by health insurance literacy ... [P]airing dynamic copays with reference pricing, layered onto a tiered network, may better address these limitations by strengthening steerage, improving OOP predictability and aligning member shopping incentives with higher-value care."  MORE >>