"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 >>
"One in five (18%) adults now report having ever taken a GLP-1 agonist, including 12% who say they are currently taking this type of medication (a 6 percentage point increase from 18 months ago). Even though most GLP-1 users say their insurance covered at least some of the cost, over half (56%) of users say these drugs were difficult to afford, including one in four who say they were 'very difficult' to afford." MORE >>
"[T]he key isn't just knowing that pooling exists; it's understanding how to manage it strategically: [1] Track large claims proactively ... [2] Evaluate pooling levels ... [3] Understand carrier behavior ... [4] Plan for the inevitable." MORE >>
27 pages. "Ninety-six percent of employers say their benefits budget has grown during the past two years ... Nearly three-quarters of organizations list health care costs as an issue their benefits program is designed to address, yet only 11 percent offer accident, critical illness, and hospital indemnity insurance.... More than one in three organizations that offer dental, vision, or supplemental health benefits say enrollment for each of these benefits is higher than expected.... Sixty-five percent of employers see room for improvement in how they communicate to employees about benefits. " MORE >>
"PBMs play a powerful role in determining which medications are accessible and affordable. Today, three PBMs process nearly 80% of prescription drug claims in the U.S., giving them immense market power. This consolidation has created a skewed marketplace that drives up drug costs, limits patient choice, and makes it difficult for employers to negotiate contract terms for medications.... These consequences are real, and they are urgent to address." MORE >>
"Eli Lilly is dropping CVS Health's drug benefit plan for its employees after the healthcare conglomerate stopped covering the company's weight-loss drug in favor of Novo Nordisk's rival medication ... Beginning January 1, Lilly employees covered by the company's medical plan will be automatically enrolled for coverage through pharmacy benefit manager Rightway ... a pharmacy benefit manager that works on a fee basis." MORE >>
"The guidance confirms that employers may offer fertility benefits as an independent, noncoordinated excepted benefit if certain conditions are met. Under this structure, fertility coverage may qualify as a specified disease or illness policy, similar to a cancer-only policy.... FAQ Part 72 also clarifies how EBHRAs can be used to provide fertility benefits, allowing a self-funded alternative." 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 >>
"[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 >>
"In response to the rising prices, employers may be considering tightening up eligibility requirements for weight-loss drugs, like increasing the BMI threshold or requiring employees to be enrolled in weight-management programs." 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 >>
"[As] Americans live longer, the challenge is not just adding years to their lives, but making sure that time includes quality, health and financial security. ... [S]peakers explored innovative strategies and systems intended to help close the gap between what people need and what the current system delivers, given today’s demographic realities." MORE >>
"The Agencies also announced that they intend to propose notice and comment rulemaking to provide additional ways that certain fertility benefits may be offered as a limited excepted benefit if certain conditions are met and are considering whether to modify the standards under which supplemental health insurance coverage provided by a group health plan, including a supplemental benefit for fertility coverage, will be considered to satisfy the conditions for being an excepted benefit." MORE >>
"An analysis of more than 190 employers and over 190,000 members found that overall pharmacy spend has increased by roughly 18% per member per month compared to the prior year. With specialty medications driving up costs and limited transparency from pharmacy benefit managers (PBMs), employers are increasingly seeking new strategies to manage expenses while ensuring that employees maintain access to essential medications." MORE >>
"The FAQs make clear that a plan may offer fertility benefits as an independent, noncoordinated excepted benefit, and thus be exempt from ACA requirements, if the following conditions are met: [1] the benefits are provided under a separate insurance policy; [2] there is no coordination between the independent benefit and any exclusion under a related group health plan; and [3] the benefits are payable without regard to whether benefits are provided for the same condition under a related group health plan." MORE >>
"Focusing on the legal and historical distinctions between Title VII and Title IX, this case limits the scope of Section 1557's protections. Although the gender-identity discrimination provisions had already been blocked from enforcement, this decision officially vacates the rules." [Tennessee v. Kennedy, No. 24-0161 (S.D. Miss. Oct. 22, 2025)] MORE >>
"[B]enefit leaders are focused first on ensuring employees feel supported and engaged before leveraging benefits as broader tools for culture, performance or reputation building. While empathetic leadership is a win for employees, there remain challenges for benefit managers in striking the right balance." MORE >>
"For fertility benefits to be considered an independent, noncoordinated excepted benefit under the regulations, [FAQs Part 72] confirms the benefits must satisfy [three specific] requirements ... The FAQs also describe situations where fertility benefits can qualify as an excepted benefit under the category of limited excepted benefits. " MORE >>
"[On] October 21, 2025, CMS ... [directed] MACs to lift the claims hold for Medicare physician fee schedule, ground ambulance transport and federally qualified health center claims, including telehealth claims that 'CMS can confirm are definitively for behavioral and mental health services.' ... CMS directed MACs to continue to temporarily hold claims for nonbehavioral and mental health services telehealth claims and for acute hospital care at home claims." MORE >>
"[This] decision departs from recent district court rulings that have been more receptive to participants' challenges to wellness-program surcharges ... Those courts deferred to the [DOL's] interpretation requiring retroactive reimbursement. The Rhode Island court, by contrast, rejected such deference under the anti-parroting doctrine and sided with employers. The case underscores the growing judicial split over how far ERISA's wellness-program rules extend and whether agency interpretations in preambles are binding." [Williams v. Bally's Management Group, LLC, No. 25-00147 (D.R.I. Nov. 4, 2025) MORE >>
"[B]etter questions can unlock better results -- for employers, employees, and consultants alike. [1] Understanding the real drivers of cost ... [2] Rethinking navigation and employee experience ... [3] Evaluating ROI and value ... [4] Strengthening the employer -- consultant partnership ... [5] Future-proofing your benefits strategy." MORE >>
"[A] handy chart (updated for this year) [describes] how each of these account types varies around eligible employers; eligible employees; the need for a plan document; who can make contributions to the account; this year's contribution limits (if any); the tax benefits to the employee and to the employer; and if investment earnings (if any) are taxed. [It also covers] funds availability to participants; any carryover provisions; portability of the account; eligible expenses to be reimbursed; substantiation requirements; and whether debit cards are available." MORE >>
"[FAQs Part 72] provide guidance on whether: [1] Employers can offer fertility benefits on a 'stand-alone' basis. [2] An excepted benefit health reimbursement arrangement (HRA) can reimburse out-of-pocket fertility expenses. [3] Fertility coverage under an excepted benefit affects an individual's eligibility to make or receive health savings account (HSA) contributions. [4] An excepted benefit employee assistance program (EAP) can offer coaching and navigator services." MORE >>
"While nearly all HR leaders (96%) say well-being is a top or constant consideration, just three-quarters of executive leaders (74%) and two-thirds of company owners (65%) share that same focus.... HR and benefit leaders may be leading the well-being charge, but greater alignment with leadership and ownership is essential to embed well-being into a broader business strategy." MORE >>
"While fertility vendors might start to offer policies, the usual carriers who offer worksite plans will more likely begin to offer a new policy. However, fertility policies may take some time to come to market, pending state insurance approvals.... Under the new guidance, employers can use these HRAs to provide fertility coverage that qualifies as an excepted benefit.... The new guidance clarifies that EAPs can cover fertility coaching and navigation services without any risk of losing their excepted benefit status." MORE >>
