News Archive

"We are seeing the migration of 401(k)-style fiduciary claims to health plans, accelerated by transparency requirements established by the Consolidated Appropriations Acts of 2021 and 2026. The unifying question is often not whether a single rule was violated, but whether the plan sponsor followed a prudent fiduciary process."  MORE >>

"This white paper examines state reinsurance programs through a financial and actuarial lens.... [The authors] highlight how reinsurance transforms previously unbounded risk into manageable exposure and creates new strategic opportunities for payers ... [and] explore how insurers can leverage these dynamics through condition-specific product strategies and consider the implications of a potentially shrinking ACA market on 1332 waiver funding and the long-term sustainability of reinsurance programs"  MORE >>

"[T]he deadline for employers covered by the San Francisco Health Care Security Ordinance (HCSO) to submit the required 2025 annual reporting form (ARF) is May 1, 2026. Employers that miss the deadline may face a $500 penalty for each quarter the reporting is delayed. The 2025 ARF, instructions and other resources are available on the city and county of San Francisco's website, along with ARF FAQs and information about the HCSO."  MORE >>

"[T]he court held that participants who received every promised benefit could still demonstrate injury in fact under Thole... by alleging they paid too much for that coverage. Second, the court declined to resolve the settlor doctrine defense at the motion to dismiss stage, holding that whether Northwestern's decisions regarding the design of coverage options constitute fiduciary or settlor functions is a 'fact-intensive' inquiry better suited for summary judgment." [Barbich v. Northwestern Univ., No. 25-6849 (N.D. Ill. Apr. 2, 2026)]   MORE >>

"This fourth extension of QPA nonenforcement relief underscores the significant operational difficulties and continued uncertainty facing plans and insurers. Plan sponsors and advisors should confirm that their TPAs or insurers are aware of this latest extension and understand its implications for ongoing claim administration and IDR proceedings"  MORE >>

"The lawsuit ... claims Northwestern violated its fiduciary duty as a plan sponsor under [ERISA]. According to the complaint, the university offered multiple preferred provider organization health plans but failed to properly evaluate and disclose that one option -- the higher-premium 'Premier PPO' -- provided no meaningful advantage over cheaper alternatives." [Barbich v. Northwestern Univ., No. 25-6849 (N.D. Ill. Apr. 2, 2026)]  MORE >>

30 pages. "This reform agenda is designed as a 'bill of rights' to ban abuses that deny care, lower deductibles, and stop premium shocks -- in other words, to respond to the growing feeling that health insurance costs too much and offers too little value or protection. A key theme of this report is that markets in health care are highly concentrated, driving up medical prices and premiums."  MORE >>

"In these many situations where AI increases productivity without necessarily improving accuracy or outcomes, or when AI can perform services autonomously, current payment paradigms that reimburse based on human labor inputs like time and skill just don’t fit well.  This may lead to overspending and overuse, which must be balanced with the health benefits of access to the technologies."  MORE >>

"In recognizing that participants can establish standing based on allegations of overpaying for benefits -- rather than needing to show denied coverage or mismanaged assets -- the court distinguished prior precedent like Thole and lowered a key procedural hurdle. Just as importantly, the judge declined to resolve whether Northwestern acted in a settlor or fiduciary capacity at this stage, emphasizing that decisions around plan design, selection, and monitoring may carry fiduciary obligations subject to later factual scrutiny." [Barbich v. Northwestern Univ., No. 25-6849 (N.D. Ill. Apr. 2, 2026)]  MORE >>

" As part of a series of multi-year voluntary commitments announced in partnership with HHS and CMS, leading health plans committed to making specific reductions to the scope of claims subject to prior authorization  ... Health plans' efforts to reduce prior authorization across the markets covered by the commitments will result in approximately 11% fewer prior authorizations occurring in 2026 -- or 6.5 million fewer prior authorizations for patients, which includes a reduction of more than 15% in Medicare Advantage."  MORE >>

"Like defined benefit pension plans, self-funded group health plans place the residual risk of payment on the employer. While there are mechanisms to smooth or reduce some of the payment risk, the plan sponsor is ultimately responsible for ensuring that promised benefits are paid in compliance with the terms of the plan. In both contexts, the participant's protected interest begins and ends with the employer's promise of future benefits, not the participant's preferred method of fulfillment. Participants do not suffer a concrete injury merely because they disagree with how the employer's promises are fulfilled."  MORE >>

"The Departments and OPM extend the exercise of enforcement discretion ... under the relevant No Surprises Act provisions for any plan or issuer, or party to a payment dispute in the Federal IDR process, that uses a QPA calculated in accordance with the 2021 methodology, for items and services furnished on or after February 1, 2026, and before October 1, 2026 ... This exercise of enforcement discretion applies to QPAs for purposes of calculating patient cost sharing, providing required disclosures with an initial payment or notice of denial of payment, and providing required disclosures and submissions under the Federal IDR process."  MORE >>

16 pages. "Inflation continues to drive high trend, pushing many plans beyond the upper thresholds of the de minimis ranges and, thus, out of compliance. Offsetting this dip, the 2027 maximum out-of-pocket (MOOP) limit increased sharply -- from $10,600 in 20262 to $12,000 in 2027 -- the largest MOOP jump to date. The proposed 2027 Notice of Benefit and Payment Parameters (NBPP) also suggests the possibility of even higher MOOP limits for Bronze and Catastrophic metal tiers up to 130%. The combined effects of these adjustments, and their implications for plan compliance and value, are examined further in the following sections."  MORE >>

"The San Francisco Office of Labor Standards Enforcement (OLSE) has opened the Health Care Security Ordinance (HCSO) Employer Annual Reporting Form (ARF) website. All covered employers must submit the required reporting on the 2025 calendar year by May 1, 2026. Employers required to complete the reporting will find many useful resources on the ARF website, including instructions, previews, an educational webinar with slides, FAQs, and the reporting form itself."  MORE >>

"In the commercial market, drug spending is substantial. Yet hospital and facility services account for the largest share of medical expenditures—and therefore represent the greatest financial exposure for self-insured employers. Understanding why requires a closer look at how these employer plans work."  MORE >>

"Dispute volume in the first half of 2025 more than doubled from the same period in 2024 -- driven largely by a small number of private equity-backed providers and IDR middlemen effectively rigging the system to extract payouts that can be 'three to nine times in-network rates' ... This provider-driven abuse of the No Surprises Act contributes to higher premium costs, fueling the health care affordability crisis impacting every American."  MORE >>

"Democrats are casting about for new health reform ideas in the hope that they can gain traction in the run-up to 2028 and be enacted afterward.... There are at least three equally important big priorities Democrats will be thinking about that are in themselves challenging and, in a world of limited dollars and political capital, will be in tension."  MORE >>

"This software is being issued only as a supplemental tool for issuers of risk adjustment covered plans to better understand and simulate the calculation of plan liability risk scores for their enrollees.... Python software is being phased in to replace the SAS software, which will be discontinued for benefit year 2026." Also available:

• Technical Details (XLSX) 
• 2025 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP)
• 2025 Benefit Year Risk Adjustment: Python Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP)

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"In 2024, the United States had an estimated population of 335 million individuals. Most of those individuals had private health insurance or were covered under a federal program (such as Medicare or Medicaid). About 8.2% of the U.S. population was uninsured. Individuals (including those who were uninsured), health insurers, and federal and state governments spent approximately $5.0 trillion on various types of health consumption expenditures (HCE) in 2024, which accounted for 17.2% of the nation's gross domestic product." [IF10830 updated Mar. 31, 2026]  MORE >>

"When you look at what UnitedHealthcare actually pays for basic office visits, the numbers are all over the map. There is no rhyme or reason to it. There is no market rate. There is only the price that a specific doctor was able to negotiate on a specific day.... If you are an employer providing health insurance, this lack of discipline is costing you a fortune. You are handing your credit card to a middleman who has no incentive to find the best price."  MORE >>

"FinCEN's Advisory provides financial institutions with an overview of how fraudsters, organized crime groups, and increasingly, transnational criminal organizations are targeting government health care benefit programs. It also highlights money laundering typologies and red flag indicators to help financial institutions identify and report suspicious activity. Today's Advisory strongly encourages financial institutions to voluntarily report suspicious activity to FinCEN and immediately notify law enforcement of such activity."  MORE >>

"Employees that underutilize preventive health care in the present may inadvertently drive higher costs in the future. ... [E]mployees can be guided on how to use their benefits more effectively....  Medical spend for members with chronic conditions has decreased 1.1% YoY, while prescription spend increased 10.6%."  MORE >>

"The success of any regulation depends on its details. Policymakers must move from the abstract to the concrete when they strive to implement a policy goal, such as lowering prices for health care services in the commercial market. This requires them to address a series of issues ranging from whether pro-competitive strategies can substitute for a regulatory approach and, if price regulation is implemented, how it should be structured. [The authors] discuss ten issues that policy makers must confront."  MORE >>

"The potential for a lower AV Bronze plan introduces additional uncertainty into the individual market. Individual regulators will need to make decisions on these new flexibilities. Issuers need to consider the risks of pricing these plans too low, as well as whether their competitors do the same. It is also important to note that these plans are occurring alongside other potential low- price plans, including expanded catastrophic plans and non-network plans."  MORE >>

"The growth of health care spending in the United States seems to have permanently slowed thanks in part to technological advances making medical treatments cheaper and more effective ... The United States spent more than $5 trillion on medical care in 2024, or 18% of its gross domestic product (GDP). That's up a bit from 17.2% of GDP in 2010, but far below the 21.2% share of GDP -- nearly $1 trillion less -- forecast by government actuaries in 2010."  MORE >>