"It appears that under the new executive order, the new administration plans to ramp up its enforcement activities to ensure that health plans remain in compliance.... Plans that have not started posting their machine-readable files, or who may not have all services posted on a public website should work with their TPA and counsel to ensure that they are in compliance."  MORE >>

"[T]his latest order -- which could result in additional regulations -- underscores the importance of health care price transparency as a policy objective for the new administration. For plans and insurers, the first Trump administration's November 2020 final regulations (which the administration now characterizes as 'paradigm-shifting') were a heavy lift complete with multi-year effective dates and far-reaching disclosure requirements."  MORE >>

"Overall, the goal of the proposed changes is to require Regulated Entities to implement stronger security controls and procedures to better protect ePHI from data breaches. Based on the number of discreet changes that are contained in the proposed rule, Regulated Entities may be required to make significant modifications to their existing security practices when the new rule goes into effect."  MORE >>

"While Notice 2025-15 provides clarity on the time and manner of the notice, it may be difficult to take advantage of the alternative method (for full-time employees) given that the legislation was issued in late 2024, and 2024 statements are due to full-time employees by March 3, 2025."  MORE >>

"The Ninth Circuit's decision underscores the importance of using validated medical necessity guidelines and supports plan administrators' discretion in making benefits determinations under ERISA. The Ninth Circuit emphasized that ambiguity and procedural irregularity in denying a claim do not alone constitute an abuse of discretion unless it affects a claimant's ability to submit responsive evidence, reinforcing the principle that decisions must be based on reasonable application of plan criteria." [K.K.; I. B. v. Premera Blue Cross, No. 23-35480 (9th Cir. Feb. 6, 2025)]  MORE >>

"Only about one in four enrollees knew that the amount is not the same for all groups of prescriptions. There also was confusion about out-of-pocket maximums.... Satisfaction with the choice of doctors and the quality of health care received were also high, with seven in 10 being extremely or very satisfied.... Sixty-two percent of enrollees have used smart health technology, such as an application for the phone, wearable device or other technology that includes the ability to sense or track activity for the purposes of managing health, either currently or in the past."  MORE >>

"The Prescription Drug Data Collection (RxDC) for the 2024 reference year must be filed by June 1, 2025, and carriers, TPAs, and PBMs have begun to reach out to employers for the information necessary to complete the filing. Some of those communications are easy to miss." [Chart shows procedures and deadlines for several health insurance carriers.]  MORE >>

Video of hearing held Wednesday Feb. 26, 2025. Testimony of witnesses: [1] Mr. Hugh Chancy, RPh, Pharmacist and Owner, Chancy Drugs; [2] Mr. Shawn Gremminger, MPH, National Alliance of Healthcare Purchaser Coalitions; [3] Mr. Anthony Wright, Families USA; and [4] Dr. Matthew Fiedler, PhD, Center on Health Policy, Brookings Institution.  MORE >>

"For Provider-Owned, Provider-Sponsored Health Plans (PSHPs), the ability to integrate care delivery and insurance operations provides unique opportunities to manage costs and improve outcomes. However, these plans also face challenges related to financial sustainability, regulatory compliance and the growing costs associated with social determinants of health."  MORE >>

"UnitedHealthcare is in the hot seat once again, this time for fraudulent Medicare Advantage billing practices, placing the health insurance giant under a civil fraud investigation by the Department of Justice. Specifically, the Department of Justice (DOJ) is evaluating the company's protocols for recording diagnoses that can result in extra payments for the company's Medicare Advantage plans[.]"  MORE >>

"The primary driver of growing commercial health care spending in the US is rising prices, driven in part by consolidation and the formation of 'megaproviders.' New data from Oregon suggest that price limits referenced to traditional Medicare rates can be an effective solution with a light administrative burden.... [A] similar scheme could be implemented more broadly ... [L]awmakers may consider separate caps for inpatient facility fees, outpatient facility fees, professional fees, and pharmaceutical-derived revenue, set below each service line's mean price. [The authors] also consider the enforcement mechanism, sufficiency of payments, and potential for a reduction in price variation."  MORE >>

"Social media outreach is not the conventional avenue through which to challenge health insurance-related delays and denials, but it can be effective.... Nearly one in five medical claims processed by [ACA] marketplace plans is denied in a given year.... This onerous and unpredictable process highlighted how administrative headaches can drive health inequities, keeping coverage out of reach for some."  MORE >>

"Deregulation is not always helpful for benefit plans.... Determining which regulations are helpful and which are not won't always be easy.... [1] Environmental, Social or Governance investing ... [2] Cryptocurrency ... [3] ESOPs ... [4] Fiduciary investment advice ... [5] Mental health substance use disorder parity."  MORE >>

"Today, the Senate Health, Education, Labor, and Pensions (HELP) Committee voted to favorably report the nomination of Lori Chavez-DeRemer to be Secretary of the U.S. Department of Labor by a vote of 14 to 9. Her nomination will now move to the Senate floor for a final vote at a later date."  MORE >>

"ERISA permits the use of actuarial assumptions to calculate the benefits due to participants and beneficiaries of defined benefit pension plans. Despite this longstanding principle of ERISA, the Appellants in Watt urged the court to rewrite ERISA and impose their own evolving standards to calculate these benefits." [Watt v. FedEx, No. 23-2593 (W.D. Tenn. Sep. 18, 2024; on appeal to 6th Cir. No. 24-5945; amicus brief Feb. 26, 2025)]  MORE >>