"[CMS] updated the 2026 out-of-pocket maximums (OOPMs) for nongrandfathered group health plans under the ACA -- $10,600 for self-only and $21,200 for other coverages, up from the 2025 amounts of $9,200 and $18,400, respectively. These amounts are higher than the 2026 HDHP out-of-pocket maximums. The updated 2026 OOPMs supersede the amounts CMS announced in October 2024 of $10,150 for self-only and $20,300 for other coverages."  MORE >>

"Paid leave goes live on 01.01.26; employers can begin payroll deductions and employees can begin applying for paid leave benefits. Employers must provide employees notice by 12.01.25. First premium payments are due on 04.30.26."  MORE >>

"A 2023 ruling by the 10th Circuit U.S. Court of Appeals will stand after the nation's highest court denied certiorari in the legal dispute over Oklahoma's Patient's Right to Pharmacy Choice Act, which regulates pharmacy benefit managers (PBMs)." [PCMA v. Mulready, No. 22-6074 (10th Cir. Aug. 15, 2023; cert pet. denied Jun. 30, 2025, No. 23-1213)]  MORE >>

"The U.S. Supreme Court ... struck down a Fourth Circuit decision that preserved access to gender-affirming care under two state-run health plans, telling the lower court to consider a recent decision by the justices that upheld a Tennessee law limiting treatments for young transgender people.... In the present combined appeal, North Carolina and West Virginia separately petitioned the Supreme Court in July 2024, after a Fourth Circuit panel affirmed lower courts' decisions that blocked laws imposing gender-affirming care bans in state-run health plans." [Kadel v. Folwell; Crouch v. Anderson, Nos. 22-1721, 22-1927 (4th Cir. Apr. 29, 2024; S. Ct. Nos. 24-90, 24-99 Jun. 30, 2025)]  MORE >>

"Group life is the redheaded stepchild of employee benefits, often added on by insurers on top of the primary products being sold to plan sponsors and employers, such as disability insurance.... [P]roblems tend to crop up in the administration of group life plans and in the payment of claims due to nothing more than the lack of attention that comes with being a relative afterthought." [Edwards v. Guardian Life Ins. of Am., No. 24-60381 (5th Cir. June 20, 2025)]  MORE >>

"The large integrated PBMs are facing continued pressure to provide transparency and models aligned with employers' and plans' interests.... The need for PBMs to take on a fiduciary duty tied to pharmacy benefits was mentioned by several respondents ... The opacity of the larger PBMs makes it nearly impossible for plan sponsors to evaluate whether their PBM is working in their best interest[.]"  MORE >>

"For disabled employees, RTO policies don't just represent a change in environment, they can become a tipping point that insurers use to challenge or deny disability claims. Understanding the interplay between workplace demands, disability accommodations, and the definition of disability in ERISA policies is essential to protecting your rights."  MORE >>

"CMS identified suspicious activity related to unauthorized creation of certain beneficiary online accounts using personal information obtained from unknown external sources.... Approximately 103,000 beneficiaries may have been impacted."  MORE >>

"This brief uses the Current Population Survey to look at the share of family income people with employer-based coverage pay toward their premiums and out-of-pocket payments for medical care.... People in lower-income families with employer coverage spend a greater share of their income on health costs than those with higher incomes, and [the] health status of family members is associated with higher health-related expenses."  MORE >>

45 pages; Jun. 30, 2025. "The HHS-operated risk adjustment program saw a slight decrease in issuer participation nationally in the 2024 benefit year, compared to the 2023 benefit year.... Risk adjustment state transfers as a percent of premiums decreased compared to the 2023 benefit year.... The amount of paid claims remains strongly correlated with risk adjustment state payments and charges[.]" 

• Appendix A: HHS Risk Adjustment Program State-Specific Data (XLSX)
• Appendix B: HHS Risk Adjustment Geographic Cost Factor (GCF) (XLSX)
• Appendix C Table 4: Issuer-Specific Information for Non-Merged Market Issuers (XLSX)
• Appendix D Table 5: Issuer-Specific Information for Merged Market Issuers (XLSX)
• Appendix E Table 8: Default Risk Adjustment Charge (XLSX)
• Appendix F Table 9: Default Risk Adjustment Charge Allocation (XLSX)

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"[1] Health Savings Accounts and Health Reimbursement Arrangements will be a large part of the administration's health plan focus going forward ... [2] Nonprofit compensation excise tax ... [3] Continuation of employer tax credits ... [4] Provisions impacting health plan Pharmacy Benefit Managers ... [5] Limited to no impact on employer retirement plans."  MORE >>