"This brief provides an overview of the role of PBMs in managing pharmacy benefits, discusses federal efforts to reform certain PBM business practices, and explains the estimated federal budgetary impact of the recently enacted legislation ... (This brief focuses on actions at the federal level and does not address state legislative efforts related to PBMs, which have occurred in all 50 states.)"  MORE >>

"Under the Biden administration, [CMS] implemented regulations that limited insurers to two nonstandard plan designs per metal level on the ACA marketplaces ... In the proposed Notice of Benefit and Payment Parameters for the 2027 plan year ... CMS said it intends to discontinue those limits as well as requirements that plans offer standardized options on the exchanges. To ease potential disruption, the agency said it will allow payers to choose whether to keep the standardized plan options they currently offer[.]"  MORE >>

47 pages; updated Feb. 2026. "Mandates requiring paid leave for an employee's own health condition exist in many states ... [Most of] these jurisdictions also require paid family leave. Voluntary group family leave insurance is now available in [eight states] ... This semiannual GRIST provides a high-level summary of these programs. This particular edition also provides an update on taxation of PFML contributions and benefits."  MORE >>

"An employer terminated an employee for alleged FMLA misuse based primarily on a single call-in conversation, without determining whether the leave was actually used for an FMLA-qualifying purpose. The court denied summary judgment on the retaliation claim, finding that a jury could conclude the employer's decision-making process was 'unworthy of credence.' When FMLA discipline rests on assumptions instead of investigation, summary judgment often disappears." [Pack v. CSX Transportation, Inc., No. 24-0688 (S.D. W.V. Jan. 14, 2026)]  MORE >>

"Two remedial measures agreed to by ESI could particularly impact pharmaceutical manufacturers: [1] ESI's commitment not to discriminate between high and low list price versions of the same drug, and [2] delinking administrative fees paid by manufacturers from the list price.... [It] is unclear how ESI and the other PBMs will negotiate rebates for high and low list price drugs going forward."  MORE >>

"This is the moment to step back and ask whether payroll and benefits are aligned, whether eligibility tracking is accurate, and whether administrative responsibilities are clearly defined. When these questions go unanswered, businesses often find themselves reacting instead of planning, making it harder to stay ahead as the year progresses. Addressing misalignment now creates breathing room later."  MORE >>

"[O]nly 45% of employers analyze employee demographics when making benefits decisions ... The utilization of traditional Employee Assistance Programs (EAPs) is typically below 10% (often under 5%), and most employees can't explain what it offers or how to access support.... Employee demographics reveal specific needs.... [Improving utilization is] about marketing to your employees versus just communications."  MORE >>

"Controlling healthcare costs does not require cutting benefits or lowering the quality of coverage. It requires moving away from short-term fixes and toward a strategy built to last.... Predictability creates stability. And stability allows business owners and HR leaders to plan with confidence rather than reacting under pressure, especially as regulatory changes and ACA updates continue to shape benefit planning decisions."  MORE >>

"[HHS] proposed tightening marketing standards and adding income verification policies for [ACA] marketplace plans starting in 2027. The proposal would expand how plans can operate in the marketplace, which regulators say could reduce fraud and lower premiums. But it may also make coverage harder to obtain for some low-income enrollees and steer more consumers toward high-deductible plans."  MORE >>

"House Judiciary Committee Republicans have subpoenaed eight [ACA] health insurers for documents as part of a widening investigation of potential fraud surrounding the use of premium subsidies in the individual market ... [The Committee] issued subpoenas to Elevance, CVS, Centene, GuideWell, Oscar Health, Kaiser Permanente, Health Care Service Corporation and Blue Shield of California."  MORE >>

"Operationalizing a risk adjustment data validation audit requires strategic planning, collaboration, and ongoing process improvement. To ensure a successful RADV outcome, it's not enough to just pass along medical records to your Initial Validation Audit (IVA). If you didn't get the RADV results you were hoping for, it could be a sign that your check engine light is on and it's time to take a look under the hood!"  MORE >>

"The brief urges the Court to allow the plaintiff's case to proceed by rejecting the defendant's motion to dismiss.... The suit ... alleges the defendants illegally exploited the IDR system by overwhelming the IDR process with hundreds of disputes they knew were ineligible, resulting in millions of dollars in improperly obtained awards. Plaintiffs' claims include violations of [ERISA, RICO], California's Unfair Competition Law, and common law fraud." [Anthem Blue Cross v. Halomd, No. 25-1467 (C.D. Calif. amicus brief filed Feb. 6, 2026)]  MORE >>

"By taking an integrated approach to managing health and retirement programs, employers can unlock meaningful tax efficiencies across health savings accounts (HSAs), flexible spending accounts (FSAs), transportation benefits, and retirement plans like 401(k)s and 403(b)s. The real driver of these savings? Increasing employee participation in tax-advantaged plans."  MORE >>