News Archive

"overruled Plaintiff's objection to a magistrate judge's order that granted in part and denied in part her motion for additional discovery in an ERISA benefits dispute. The decision walks through several recurring fights over the scope of ERISA discovery and the contents of the administrative record, and it resolves each one against Plaintiff." [Mayor v. Metropolitan Life Ins. Co., No. 25-0012 (D. Utah June 24, 2026)]  MORE >>

"Overwhelmingly, the survey participants are familiar with their mental health benefits, and they trust the information they get about them....More than half of workers who are caregivers said people are encouraged to use mental health benefits, and it feels normal to do so compared to less than half of workers who are not caregivers. Normalized use of mental health benefits differs by industry, from a high of 50 percent of workers at professional services firms to a low of 23 percent of workers in construction."  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 >>

"[T]he Proposed Rule would, for the first time, allow employers to offer fertility benefits -- including in vitro fertilization (IVF) -- outside the federal market requirements added by [HIPAA], the [ACA] and related statutes. However, that offer of fertility benefits is also subject to some conditions."  MORE >>

"Although not intended, the new federal programs have the potential to introduce both direct and indirect medical and drug costs to group-based plan sponsors, beginning as early as July 2026. Further, if the BALANCE Model launches as planned in 2028, group-based plan sponsors will face a decision. They can participate in the program to offer GLP-1s to retirees on a group basis and take on the associated costs or they can direct retirees to the individual Medicare marketplace to obtain GLP-1s and other Medicare medical, drug, and ancillary benefits."  MORE >>

"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 >>

"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 >>

"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 >>

"[T]wo-thirds of clients (66%) currently cover GLP-1s for obesity, and most intend to continue doing so. Few clients that do not cover GLP-1 drugs for obesity are considering adding them.... This finding is consistent with [WTW's] 2025 Best Practices in Healthcare Survey, where 57% of employer respondents indicated coverage of GLP-1 medications for obesity.... 74% are considering or already using a clinical wrap to support appropriate utilization, engagement and outcomes."  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 >>

"Plan sponsors that are considering offering a large behavioral health network should note that its effectiveness will depend more on thoughtful design, governance and deployment than on the size of the network. This article describes large behavioral health networks and their appeal. It also covers things to consider before choosing a large behavioral health network. Additionally, it outlines four steps that plan sponsors can follow to ensure the successful introduction of a large behavioral health network."  MORE >>

"In enforcement actions and audit findings, regulators have consistently identified deficiencies in comparative analyses, particularly where plans cannot adequately document how NQTLs are designed and administered. The most common MHPAEA compliance challenges [include] ... [1] Data access and vendor dependency.... [2] Identifying all applicable NQTLs.... [3] Explaining factors and evidentiary standards ... [4] Demonstrating operational compliance.... [5] Ongoing maintenance obligations.... [6] Fiduciary responsibility.... If this process appears to be complex and overwhelming, that’s because, quite honestly, it is."  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 >>

"Immediate actions (before final rule): [1] Inventory existing fertility benefits.... [2] Assess state requirements.... Planning (once final rule is published): [1] Decide whether to adopt excepted fertility benefits.... [2] Choose a delivery structure.... [3] Set benefit parameters.... [4] Prepare required participant notices.... [5] Review summary plan descriptions (SPDs) and plan documents ... [5] Coordinate with benefits counsel on tax treatment."  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 >>

"Start with the question. ... Validate the data. ... Integrate quantitative and qualitative data. ... Use a sequential process to analyze data. ... Look at the data through multiple lenses. ... Don’t overreact to outliers. ... Put the pieces together."  MORE >>

"Healthcare costs aren't evenly spread. A small group of members accounts for a disproportionate share of spending. Today, 1% of members drive 21% of costs, and 5% drive half. That concentration is only intensifying. High-cost claimants, those with over $100,000 in annual spend, have grown 61% in just a few years. No deductible can solve that."  MORE >>

"Maryland District Judge Brendon Hurson tossed multiple elements of the regulation, including a $5 penalty for automatic re-enrollments and an element that would revoke guaranteed coverage for people who have past-due premiums. In addition, the court vacated a shortened enrollment period for the 2027 plan year, new eligibility verifications for special enrollment periods and plans to eliminate a 60-day extension that would allow individuals to address inconsistencies in household income[.]" [City of Columbus v. Kennedy, No. 25-2114 (D. Md. Jun. 12, 2026)]  MORE >>

"The lengthy payment rule is an annual exercise in which the Centers for Medicare & Medicaid Services, which oversees the ACA, can set new standards for coverage. The rule for next year is more ambitious than in past years, with changes to how plans are designed, eligibility verification, and adjustments needed to implement congressional legislation, along with technical updates."  MORE >>

"[PwC estimated] that medical costs will go up by 9% in the employer market next year, and by 8.5% in the individual market. One of the largest drivers is providers' use of AI-enabled software and scribes that more thoroughly document the care that's delivered.... PwC said the financial impact isn't so much due to people using more medical services as 'changes in coded severity, case mix and paid amount per claim.' "  MORE >>

"Fiduciary oversight in health plan consulting means an advisor accepts legal accountability for acting in the plan's best interest, not just advisory responsibility, but a formal, contractual commitment to prudent plan stewardship. For self-funded employers, understanding why this standard is gaining traction is increasingly important as regulatory scrutiny and litigation risk around health plan management continue to grow."  MORE >>

"Even when ICHRA isn't the right fit, it creates leverage. Employers may get an ICHRA quote showing six- or seven-figure cost savings -- and, whether they switch or not, that quote puts pressure on the current carrier to negotiate. For smaller businesses, especially, that kind of leverage didn't exist before. This is about power. That leverage disappears if you're pitching ICHRA on the wrong assumptions -- and many brokers are, because the two biggest assumptions they bring to it are outdated."  MORE >>

"In an amicus brief ... the ERISA Industry Committee and the American Benefits Council backed Compass Group's bid to appeal a Missouri federal judge's decision to grant class certification in a lawsuit challenging tobacco-use surcharges imposed through the company's health plan." [Mehlberg v. Compass Group USA, Inc., No. 24-4179 (W.D. Mo. Apr. 15, 2025; on appeal to 8th Cir. No. 26-8007)]  MORE >>

"Employers and their advisors should be aware that HHS will not take action based on the gender identity provisions of the 2024 regulations while the vacatur remains in effect, but the remainder of the 2024 regulations continues to apply, and other federal nondiscrimination laws -- including Title VII of the Civil Rights Act, as interpreted by the U.S. Supreme Court -- may independently address gender identity discrimination in certain contexts"  MORE >>