37 pages. "This year's letter includes a new subsection, 'Coverage of OTC Drugs, Products, and Supplies' to incorporate related guidance based on Carrier Letter 2024-18. Additionally, this letter clarifies policies on formulary management, utilization management, pharmacy network management, specialty drug management, medication management, opioids, member experience and transparency, cost containment, Medicare benefits, data, and population health. Within formulary management, OPM clarifies policies on formulary decision-making, formulary exceptions, formulary designs, new- to-market drugs, biosimilars, formulary reviews, and mid-year formulary changes. Within population health, OPM clarifies policies on tobacco cessation, preventive services, contraception, fertility benefits, coronavirus disease 2019 (COVID-19), and anti-obesity medications. Additionally, within population health, OPM has removed the subsection on gender affirming care and services."  MORE >>

"Effective January 1, 2025, the special COVID-era rule under the CARES Act that allowed employers sponsoring high-deductible health plans to provide free telehealth visits without affecting employees’ eligibility to contribute to health savings accounts (HSA) has expired. Employers must now either ensure that telehealth services are preventive or subject to the plan’s deductible, or they must charge for such services in order to maintain HSA eligibility for their employees."  MORE >>

"The court conceded that the administrative proceeding was initiated as a reaction to BlueCross's denial of B.C.'s claims. But the court was persuaded that the claims denial was not the basis for the state administrative proceeding, but instead merely provided evidence to the Insurance Commissioner that BlueCross was violating New Hampshire insurance law." [Bluecross Blueshield of Tennessee, Inc. v. Nicolopoulos, No. 24-5307 (6th Cir. May 8, 2025)]  MORE >>

"In a motion to stay proceedings in a lawsuit challenging those regulations, the [Departments] notified the court that they intend to: [1] Reconsider the regulations, with the possibility of rescinding or modifying the rules. [2] Issue a policy of non-enforcement for the new regulatory requirements taking effect in 2025 and 2026. [3] Re-examine their enforcement policy under the MHPAEA more broadly.... The court granted the Departments' motion ... but requiring them to report back to the court on their progress every 90 days." [ERIC v. HHS, No. 25-0136 (D.D.C. complaint filed Jan. 17, 2025; HHS motion for abeyance filed May 12, 2025, granted May 12, 2025)]  MORE >>

"While the specific scope of any non-enforcement policy is not yet clear, the ERIC lawsuit generally focuses on those provisions which ERIC argues present an overreach by the Departments and are unduly burdensome to plan sponsors, including the meaningful benefits requirement, the material differences in access standard, and the requirement for a fiduciary certification of the comparative analyses." [ERIC v. HHS, No. 25-0136 (D.D.C. complaint filed Jan. 17, 2025; HHS motion for abeyance filed May 12, 2025, granted May 12, 2025)]   MORE >>

"In litigation arising out of a life insurance claim denial, a Colorado district court held that the employer/plan administrator breached its fiduciary duty under [ERISA] by failing to provide a participant accurate and complete information about the need to convert a group life insurance policy to an individual policy. The district court awarded the participant's surviving spouse $633,000, representing lost benefits, as surcharge relief under ERISA." [Watson v. EMC Corp., No. 19-2667 (D. Colo. May 7, 2025)]  MORE >>

"Employers who have paid Section 4980H penalties may be eligible for a refund and may want to consider filing a protective refund claim before the statute of limitations expires. Employers currently facing IRS assessments for Section 4980H penalties may have grounds to challenge the enforcement of the employer mandate." [Faulk Company, Inc. v. HHS, No. 24-0609 (N.D. Tex. Apr. 10, 2025)]  MORE >>

"These cases a.... show a possible reticence of courts to accept the presumptive disability status of individuals diagnosed with obesity. However, even if a court were to find that obese individuals are presumptively disabled, courts may still be skeptical of arguments ... that exclusions for weight loss treatment can be considered a proxy for obesity." [Whittemore v. Cigna Health and Life Ins. Co., No. 24-0206 (D. Me. Feb. 12, 2025); Holland v. Elevance Health Inc., No. 24-0332 (D. Me. Apr. 9, 2025)]  MORE >>

"The proposed changes to HSA rules include: [1] Allowing individuals who enroll in Medicare Part A to be HSA-eligible ... [2] Adding the ability to use an HSA for gym memberships and other similar physical exercise/activity costs of up to $500/year; [3] Allowing both spouses to make the $1,000 catch-up contribution (available at age 55+) to the same HSA ... The proposed changes to ICHRA rules include: ... [1] Adding a new requirement to include the ICHRA amount available on the employee's Form W-2 ... [2] The creation of an employer tax credit for offering an ICHRA."  MORE >>

"It remains to be seen whether Congress would pass legislation allowing HHS to negotiate pricing with manufacturers on behalf of the millions of group and individual health plans throughout the United States.... Continued expansion of drug importation could have a positive effect on cost reduction more widely.... [E]xpansion of biosimilars, expansion in 340(b) hospital programs and other reforms long championed by Rx reformers could lead to a broader impact on prescription drug pricing."  MORE >>

"In the wake of last year's killing of Brian Thompson, UnitedHealthcare's CEO, there has been an increased amount of public discourse around health insurance and health insurers in the U.S.... At the heart of this debate lies an unchallenged assumption: that insurance companies exist to pay for unlimited care to all, at all times, without concern for cost. This is not how insurance works. This is not how any rational system of resource allocation works."  MORE >>

"A recent federal court ruling ... quietly affirms that once a plan adopts a reasonable and consistent reimbursement methodology, fiduciaries may not just be allowed to decline provider negotiation -- they may be required to do so in order to protect plan assets and ensure uniformity across participants. That is, if your plan language is clear and your pricing structure is objectively defensible, engaging in post-claim negotiation may actually expose you to fiduciary risk." [Mejia v. Credence Mgmt. Solutions, No. 23-2028 (C.D. Calif. Apr. 21, 2025)]   MORE >>

"The House Committee on Ways and Means has released draft text of a budget bill and a section by section summary ahead of a full committee markup of the bill ... [1] ABLE provisions extended ... [2] 529 account usage expanded ... [3] New savings account proposed ... [4] HSA usage expanded ... [5] IRC Sec. 162(m) aggregation rule added."  MORE >>