News Archive

"[T]here are a variety of creative options for employers who want to provide access to GLP-1 drugs prescribed for weight loss but who also want to contain costs. But, as with any benefits program, each employer must carefully consider the associated risks with these options and ensure they can be tailored to suit the employer's individual needs. These options include health reimbursement accounts and health flexible spending accounts."  MORE >>

"More than 50 lawsuits have been filed against employers challenging their imposition of a premium surcharge on participants who use tobacco.... The recent decisions by the Eastern District of Missouri and the District of Rhode Island mark a potential shift in favor of employers in the current wave of tobacco premium surcharge litigation." [Plesha v. Ascension Health Alliance, No. 24-1459 (E.D. Mo. Feb. 3, 2026)]  MORE >>

25 pages. "To help members overcome barriers to accessing behavioral health care, some health insurers have introduced behavioral health navigation services.... Services are generally available to all members ... with some models tailored to specific populations such as adolescents or people with SUD.... There are currently no widely adopted, formal standards specifically governing the delivery of behavioral health navigation services by insurers."  MORE >>

"[T]he CAA includes several reforms to the pharmacy benefit manager (PBM) industry that represent a major step forward for meaningful health care reform. The PBM provisions included in the final legislation help shine a light on PBM business practices, promote transparency, and ensure that negotiated savings benefit plan sponsors and patients -- not middlemen."  MORE >>

"The Federal Departments released proposed Transparency in Coverage (TiC) regulations to improve the public disclosure of prices for medical items and services. [This article describes] [1] The issues that make pricing data challenging to download, understand or consume. [2] Four new files to provide additional pricing context: Change Log, Utilization, Taxonomy and Text. [3] Changes to the INN Rate and OON Allowed Amount Files, which are intended to reduce the size of the Files and increase the amount of usable pricing data."  MORE >>

"PMCA's arguments in favor of ERISA preemption of the fiduciary standards provision for self-funded employer plans center around three main points: [1] It makes an impermissible reference to ERISA plans because it specifically references 'self-insured employer plans'; p2[ It regulates in a field already fully occupied by federal standards ... and [3] It requires plan sponsors to design or structure their plan in a particular way[.]" [Pharmaceutical Care Management Association v. Bonta, No. 26-0012 (C.D. Calif. complaint filed Jan. 2, 2026)]  MORE >>

"Rising healthcare costs and unpredictable renewals are pushing more employers to explore self-funded insurance as a smarter alternative to fully insured plans.... A typical self-funded plan includes: [1] Third Party Administrator (TPA) ... [2] Stop-Loss Insurance ... [3] Pharmacy Benefit Manager (PBM) ... [4] Targeted support for areas like diabetes, MSK, or mental health ... [5] Alternative pricing strategies including reference-based pricing."  MORE >>

"The new schedule reduces the number of vaccines universally recommended for children and adolescents from birth to 18 years old.... Importantly, all vaccines remain available and covered under federal requirements, meaning families should not face out-of-pocket costs for preventive immunizations."  MORE >>

"Peter Nelson, who leads the branch of [CMS] that oversees private health insurance and Marketplaces, has pitched an ambitious vision for how compacts could be used. CMS recently requested and received input from the National Association of Insurance Commissioners (NAIC) as a prelude to rulemaking.... [ACA Section 1333] it permits the sale of health insurance that departs from many of a state's insurance rules, But Sec. 1333 generally provides no authority to depart from federal law or provide federal funding. And it is doubtful that compact plans could share a risk pool across states."  MORE >>

"44.9% of all health care payments across all lines of business were tied to APMs that hold providers accountable for quality and cost of care (HCPLAN Categories 3-4) in calendar year (CY) 2024 compared to 45.2% in CY 2023. 28.7% of health care payments across all lines of business were tied to APMs with downside risk (HCPLAN Categories 3B-4) in CY 2024 compared to 28.5% in CY 2023."  MORE >>

"One in three insured adults in the U.S. say they find prior authorizations a 'major burden' to getting health care. An additional four in ten (37%) say the process is a 'minor burden,' bringing the total share of insured adults who find the process burdensome to about seven in ten (69%). This is larger than the share who say other aspects are burdensome such as understanding bills or what is owed (60%), getting needed appointments (60%), or finding providers who accept their insurance (53%)."  MORE >>

"The Committee for a Responsible Federal Budget just dropped a detailed analysis on implementing RBP for the Federal Employee Health Benefits program. Buried in there is a roadmap for what ANY employer can expect when they stop letting hospitals yank them around with astronomical chargemaster pricing and just as phony carrier 'discounts.' The government's proposed pricing target amount of 200% of Medicare will deliver about 12% total savings. Go to 150% of Medicare? You're looking at 22% savings. Even at 250%, you still get 5-6% back."  MORE >>

"The complaints generally allege that the employers offering these programs could and should have negotiated lower premiums. According to the plaintiffs, the higher premiums may be the result of potentially excessive broker commissions, and excessive compensation to the consultants that administer them. The complaints speculate that employers offer these voluntary benefit programs without first engaging in a request for proposal process."  MORE >>

"The default approaches are either to immediately move the continuing employees to the buyer's health plan or to continue coverage under the seller's health plan for a transitional period. However, in some situations (particularly where the buyer does not acquire the seller's health plan) the parties will consider a variety of health coverage alternatives for the continuing employees. Each of these alternatives comes with multiple potentially significant issues[.]"  MORE >>

"EBRI research has examined the premium implications of expanding pre-deductible coverage in high-deductible health plans (HDHPs) paired with HSAs ... This analysis of IRS Notice 2019-45 found little to no impact on premiums. More recent EBRI research extending pre-deductible coverage to a much broader set of 116 drug classes similarly found that estimated premium increases remained modest."  MORE >>

"How could an eye doctor be in-network and out-of-network at the same time? ... UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic's services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.... [A] UnitedHealthcare spokesperson ... said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals."  MORE >>

"The proposed Great Healthcare Plan is aimed at reducing prescription drug costs, lowering insurance premiums, and expanding transparency in the healthcare system. While the proposal requires congressional action and may evolve significantly, it highlights policy priorities that could shape future legislation and regulatory initiatives impacting employer-sponsored health and welfare plans."  MORE >>

"Selecting a carrier with strong financial backing may provide greater possibility that they can handle large claims, even in catastrophic situations.... The best carriers go beyond basic coverage, offering predictive analytics, specialty drug management, and alternative care programs.... Partnering with a carrier that offers pricing stability and customized solutions can help you adapt over time, and may help reduce volatility in your benefits strategy."  MORE >>

"The average value of APTC subsidies was originally designed to be worth 5% less to workers than the ESI tax exemption, in order to maintain incentives for employers to provide health-care benefits. But the expanded subsidies average 65% more than the value of the ESI tax exemption. If all employers stopped offering health-care coverage to workers, to allow them to claim these expanded subsidies, it would increase the cost to the federal budget by $250 billion per year."  MORE >>

"[T]he Department plans to continue to devote many more resources to health and welfare plan enforcement. In particular, DOL highlights two projects for 2026: [1] barriers to mental health and substance use disorder benefits (MH/SUD), and [2] surprise billing.... DOL continues to pursue a variety of projects to protect the benefits of retirement plan participants.... [T]he Department for the first time included cybersecurity on the national enforcement project list."  MORE >>

"The Trump Administration is launching TrumpRx, a platform to connect patients seeking lower cost prescription drugs with direct-to-consumer (DTC) programs offered by manufacturers and other private companies to cash-paying patients. These DTC programs create opportunities for cash-paying patients to obtain prescription drugs at lower prices than may be available through other avenues. This Special Advisory Bulletin explains when a pharmaceutical manufacturer's offer and sale of lower cost prescription drugs to Federal health care program enrollees through a DTC program is low risk under the Federal anti-kickback statute."  MORE >>

"Workers reported similar satisfaction with their benefits package as in prior years, with top suggestions for improvement being a greater employer contribution and more flexibility of benefits to choose from.... Workers were somewhat open to using artificial intelligence (AI) as a tool to help navigate benefits and finances, but significant shares were skeptical."  MORE >>

15 pages. "Unlocking the potential to grow sustainably is a key challenge for many health insurers, especially in the face of high medical inflation driven by medical advancements, heightened geoeconomic uncertainties and ageing societies.... This article explores the use of a capital optimization solutions framework that aims to maximize strategic value from available capital resources while ensuring that firms' regulatory requirements and other business constraints continue to be met."  MORE >>

"Section 1333 of the ACA allows states to enter agreements under which Marketplace plans following the rules of one state can be sold in other states in the compact.... No implementing regulations have been released, and no state has sought to use it.... Peter Nelson, who leads the branch of [CMS] that oversees private health insurance and Marketplaces, has pitched an ambitious vision for how compacts could be used. CMS recently requested and received input from the National Association of Insurance Commissioners (NAIC) as a prelude to rulemaking."  MORE >>

"For independent pharmacies, this lawsuit highlights a recurring and frustrating reality: When states attempt meaningful PBM reform, ERISA often becomes the battleground.... [The case] reinforces a key takeaway: lasting and sustainable PBM reform may ultimately require federal action and not just state based regulation." [Pharmaceutical Care Management Association v. Bonta, No. 26-0012 (C.D. Calif. complaint filed Jan. 2, 2026)]  MORE >>