"[T]he regulations are dense, the calculations to ensure parity are complex, and [TPAs] rarely provide a sufficient NQTL Analysis.... The DOL Office of Inspector General.... is currently urging Congress to pass legislation to enhance the DOL's enforcement authority ... and ... urging DOL to use other enforcement tools ... [A chart outlines] some plan design and plan administration issues employers may want to consider now."  MORE >>

"In justifying the need for this follow-on executive order, [EO 14221] referenced several economic analyses that assert various expected benefits for consumers, employers, and insurers as a result of pricing transparency requirements. The EO also asserts that hospital and health plans have not been sufficiently compliant with the regulatory framework that emerged from EO 13877."  MORE >>

"Employers can provide a combined 'bank' of time, which includes paid time off, vacation, and sick time, so long as the policy pertaining to those hours provides at least the same benefits as provided by ESTA and may be used for the same purposes, under the same conditions, and accrued or provided for at a rate equal to or greater than that described in ESTA."  MORE >>

"The Justice Department's years-long court battle to force UnitedHealth Group to return billions of dollars in alleged Medicare Advantage overpayments hit a major setback ... when a special master ruled the government had failed to prove its case. In finding for UnitedHealth, Special Master Suzanne Segal found that the DOJ had not presented evidence to support its claim that the giant health insurer exaggerated how sick patients were to illegally pocket more than $2 billion in overpayments." [Poehling v. UnitedHealth Group, Inc., No. 16-08697 (C.D. Calif. special master report Mar. 3, 2025)]  MORE >>

"In April, the U.S. Supreme Court will hear arguments ... [on] whether the [ACA's] requirement that insurers cover preventive care at no cost to patients is constitutional.... If SCOTUS rules in favor of Braidwood's position, ... some people with employer-sponsored health insurance would pay substantial amounts for certain preventive services, but employers would not get huge savings due to relatively low spending on preventive care[.]" [Braidwood Mgmt, Inc. v. Becerra, No. 23-10326 (5th Cir. Jun. 21, 2024; cert. pet. granted Jan. 10, 2025)]  MORE >>

48 pages; Dec. 2024. "Plan and claim administrators should have a duty to provide and receive documents through electronic means.... The Department should develop model language and model forms, including a model EOB, for use in the claims and appeals process.... The Department should revise existing regulations relating to urgent care claims and appeals to reduce the 72-hour timeframe wherever possible.... [T]he Department should require disclosure of whether AI was used to make a benefit determination.... Plans must use individuals with appropriate clinical training and experience to conduct peer review of claims."  MORE >>

"This memo examines the legal framework governing hospital pricing disputes ... where a patient has agreed to pay for medical services but was not provided with a specific price beforehand.... The primary focus here is how courts evaluate hospital charges' enforceability and whether patients or insurers may be compelled to pay the full chargemaster rate. The analysis extends to the role of Reference-Based Pricing (RBP) health plans, particularly those governed by ERISA ... This memo assesses the legal standing of such plans in disputes over hospital pricing."  MORE >>

"[T]he Provider-Sponsored or Provider-Owned Health Plan (PSHP) market has emerged as a key player in the broader health insurance ecosystem.... This model enables healthcare systems to integrate care delivery and financing, allowing for better care coordination, improved patient outcomes, and more efficient cost management. This paper will examine the PSHP market by market segment, explore the trends that are unique to these plans, assess their performance relative to traditional health insurers across different lines of business and outline their key priorities for the next five years."  MORE >>

"West Virginia insurance regulators have evidence that requiring pharmacy benefit managers to pass all prescription drug rebates through to employers could lead to huge premium savings in the small-group health insurance market. A new report posted by the state's Office of the Insurance Commissioner shows that a state PBM rebate pass-through law cut the average 2025 small-group rate increase by 52%.'

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