"The court reasoned that a participant who meets the wellness program criteria during the plan year under a reasonable alternative standard has the same reward as a participant who meets the criteria at the beginning of the year: the absence of a prospective surcharge. On that reading, the court held that failure to offer retroactive refunds does not itself render the program discriminatory.... The court declined to impose an exhaustion requirement, reasoning that the claims were statutory, not benefit denials." [Williams v. Bally's Management Group, LLC, No. 25-00147 (D.R.I. Nov. 4, 2025)] MORE >>
"With the issuance of the final forms and instructions ... filers should have all the tools they need to prepare for filing the 2025 forms. Filers should note the Paperwork Burden Reduction Act and the Employer Reporting Improvement Act changes, including that forms can be delivered electronically with consent, the date of birth can be used if a TIN isn't available, and ACA penalty assessments have a six-year limit starting with returns due after December 31, 2024" MORE >>
"The GCPCA attests to a health plan's (or insurer's) compliance with the prohibition against 'gag clauses' in any agreements with providers, provider networks, or entities offering provider network access -- including downstream agreements entered into by plan service providers.... An attestation of compliance with the gag clause prohibition must be made by December 31 each calendar year." MORE >>
18 pages, rev. Oct. 30, 2025. "[This document] contains general and program specific testing information for use with ACA Assurance Testing System (AATS).... Software Developers must pass IRS AATS scenarios for the forms and tax year that the software package will support.... Transmitters and Issuers must pass a one-time communication test for the forms they will file." MORE >>
The IRS has now released all of the 2026 benefit limits, including both the cafeteria and health plan limits as well as all of the qualified retirement plan limits. Earlier this year, IRS also released the High Deductible Health Plan (HDHP) and Health Savings Account (HSA) limits. This chart shows all of these limits for 2025 and 2026. MORE >>
"As the drug pipeline expands, [prior authorization (PA)] has evolved from a transactional checkpoint into a mechanism of clinical governance. Yet, when pharmacy benefit managers (PBMs) oversee both utilization management and dispensing, financial incentives can influence coverage decisions. This overlap has prompted closer attention to how the PA function can maintain neutrality and transparency across stakeholders." MORE >>
"ALEs must furnish the 2025 Forms 1095-C to employees no later than March 2, 2026. Alternatively, ALEs have a new option available to instead post an online notice of availability for employees to request their form. Regardless, ALEs must electronically file the Forms 1094-C and 1095-C with the IRS no later than March 31, 2026. Non-ALEs sponsoring a self-insured plan (including a level funded plan) face the same deadlines for the Forms 1094-B and 1095-B."MORE >>
"Employers should closely review the Forms 1094-C and 1095-C before submitting the Forms to the IRS. Critically, all employers should collect a receipt ID from their service provider and make sure the 'Yes' box is checked on line 23 of the Form 1094-C assuming the employer offered minimum essential coverage to at least 95% of its full-time employees and their dependents. The codes entered on lines 14, 15, and 16 should also be verified for accuracy." MORE >>
"The court found that the disputed surcharge did not violate rules prohibiting discrimination on the basis of a health-status related factor under [ERISA] ... The court also concluded that the participant lacked Article III standing to bring a fiduciary breach claim under ERISA." [Williams v. Bally's Management Group, LLC, No. 25-00147 (D.R.I. Nov. 4, 2025)] MORE >>
"Recent guidance from both the [DOL] and the New York State Department of Financial Services (DFS) underscores the importance of due diligence and ongoing oversight of ... third-party administrators (TPAs), carriers, and technology platforms ... Outsourcing the administration does not absolve you of your fiduciary duty.... Here's a checklist to guide your due diligence related to cybersecurity." MORE >>
"The hidden risks of all-in-one HR technology ... SaaS vs. licensed software ... How to choose the right benefits tech partner ... Client support: Why it's critical in benefits administration ... Personalization: The keys to benefits engagement and utilization ... How to evaluate AI for HR and benefits administration ... Making the decision that serves you long term." MORE >>
"[H]aving a vendor partner complete the analysis is somewhat like asking a fox to guard the henhouse. A third-party review gives an unbiased, objective perspective to provide accurate evaluations of a carrier's adherence to regulations and standards. This independence improves credibility with stakeholders, identifying potential risks by providing a more comprehensive review of industry practices, and is often necessary for demonstrating compliance to external parties like the [DOL] or plaintiff's attorneys." MORE >>
"UnitedHealthcare's new policy says remote patient monitoring (RPM) is only medically necessary in two instances: to treat chronic heart failure and hypertension during pregnancy. It explicitly says the use of RPM for Type 2 diabetes and hypertension -- two of the most popular uses of RPM -- will no longer be covered." MORE >>
"Almost 4 in 10 disputes submitted to the IDR process are deemed ineligible by insurers, often due to errors such as resubmitted cases, claims covered by state laws, or services involving in-network providers. Both payers and providers face mounting costs and delays as IDR entities struggle to filter invalid cases, complicating cash flow for health systems. CFOs should tighten eligibility checks, track dispute-to-payment metrics, and align closely with revenue cycle teams to minimize rejected filings and improve reimbursement efficiency." MORE >>
"When faced with a document they can't decode, members often disengage until a problem (like an unexpected bill) forces them back in. This defensive strategy might protect users' mental bandwidth in the short term, but the accompanying 'avoidance penalty' leads to real costs on both sides. Confused members delay payments, call support more often, and dispute bills they don't understand. They also lose the ability to plan for healthcare expenses or make confident care decisions -- leaving them frustrated and financially uncertain." MORE >>
22 pages; Oct. 30, 2025. "Employers no longer have to automatically send Form 1095-C to individuals. The requirement for furnishing the statement is met if the employer responsible for providing the statements provides clear, conspicuous, and accessible notice on its website that an individual may request a copy of their statement and the copy is timely furnished. For this purpose, the statement is timely furnished if provided to the individual no later than the later of January 31, 2026, or 30 days after the date of the request." [Also available: 2025 Form 1094-C and 2025 Form 1095-C] MORE >>
Oct. 22, 2025. "What's New ... Employers no longer have to automatically send Form 1095-B to individuals. The requirement for furnishing the statement is met if the entity responsible for issuing the statements provides clear, conspicuous, and accessible notice on its website that an individual may request a copy of their statement and the copy is timely furnished. For this purpose, the statement is timely furnished if issued to the individual no later than 30 days after the date of the request." [Also available: 2025 IRS Form 1094-B and 2025 IRS Form 1095-B] MORE >>
"File Form 8928 to report the tax due on the following failures by group health plans or employers. [1] A failure to provide a level of coverage of the costs of pediatric vaccines ... that is not below the coverage provided as of May 1, 1993. [2] A failure to satisfy continuation coverage requirements under section 4980B. [3] A failure to meet portability, access, renewability, and market reform requirements ... [4] A failure to make comparable Archer medical savings account (MSA) contributions ... [5] A failure to make comparable health savings account (HSA) contributions[.]" MORE >>
"By recognizing the multifaceted challenges posed by disasters and implementing strategies to mitigate their impact, you can alleviate workplace stress, strengthen employee engagement and foster a workplace culture that prioritizes well-being and resilience.... Establish a comprehensive communication plan ... Elevate mental health benefits and resources ... Leverage insurance carrier support ... [Establish] a template of disaster-specific policies and resources." MORE >>
"For plan years ending January 2026 through September 2026, PCORI fees are not due until July 31, 2027. This breaks down more specifically as follows: $3.47 per covered life for plan years ending in January through September of 2025 ... $3.84 per covered life for plan years ending in October through December of 2025 ... $3.84 per covered life for plan years ending January through September of 2026." MORE >>
"Employers with a calendar-year health plan should have procedures in place to make sure they file IRS Form 720, Quarterly Federal Excise Tax Return, and pay their PCORI fee at a rate of $3.84 per covered life on or before July 31, 2026." MORE >>
"The applicable dollar amount that must be used to calculate the fee imposed by sections 4375 and 4376 for policy years and plan years that end on or after October 1, 2025, and before October 1, 2026, is $3.84. The increase from the prior applicable dollar amount is calculated by multiplying $3.47 ... by the percentage increase of the projected per capita amount of National Health Expenditures published by HHS on June 24, 2025.... The percentage increase is calculated after adjustment to reflect updates to the data used to calculate the prior applicable dollar amount, $3.47[.]" MORE >>
"[1] My recordkeeper is the plan administrator.... [2] Nobody is complaining about our service providers or investments, so everything is fine ... [3] Our investment adviser is solely responsible for investment decisions.... [4] We must sign or approve whatever our recordkeeper sends us.... [5] Our fiduciary responsibilities apply only to our 401(k) and pension plans.... [6] We can do everything ourselves." MORE >>
94 pages. "[T]his GRIST summarizes the relevant year-end 2025 and 2026 compliance and policy developments expected to affect health and fringe benefit plans and leave programs and suggests action steps for employers. Topics covered include ... [1] Congressional outlook.... [2] Regulatory outlook.... [3] Litigation outlook.... [4] State outlook.... [5] Top 10 2026 health and leave benefit planning. " MORE >>
"SB 41 goes beyond federal pricing transparency reforms by imposing an explicit fiduciary duty on PBMs to act in the best interests of their payer clients, which include both self-insured and fully insured ERISA health plans. The law also prohibits spread pricing, mandates pass-through rebates, requires state licensure, and introduces comprehensive disclosure obligations. Collectively, these provisions mark a fundamental shift in PBM accountability and create new compliance priorities for health plan sponsors, insurers, and other payers in California." MORE >>
