"The final policy may impact health plans that are not directly required to provide EHB, such as self-insured group health plans and large-group market fully insured plans that must follow the annual and lifetime dollar-limit restrictions on EHB and annual cost-sharing limitation requirements.... The final policy is consistent with CMS' desire to provide the 'regulatory framework' for innovation, without mandating it.... Issuers should plan to follow the timelines as outlined by their State and CMS. This policy is subject to litigation in Columbus II. "  MORE >>

"The court explained that a suit for benefits due must be brought against a party with an obligation to pay, which is the entity that controls benefit determinations. Here, the plan and the summary plan descriptions consistently identified Prudential as the Claims Administrator with discretionary authority to process and decide claims, while Accenture, as Plan Administrator, retained authority only over limited matters such as eligibility." [Justman v. Accenture LLP, No. 25-2084 (3d Cir. June 17, 2026)]  MORE >>

"Plan sponsors that are considering offering a large behavioral health network should note that its effectiveness will depend more on thoughtful design, governance and deployment than on the size of the network. This article describes large behavioral health networks and their appeal. It also covers things to consider before choosing a large behavioral health network. Additionally, it outlines four steps that plan sponsors can follow to ensure the successful introduction of a large behavioral health network."  MORE >>

"Request disclosure of rebates for all formulary drugs.... Examine how rebates, guarantees and exclusions are defined in the contract. Small nuances in contract language can drive costs over time.... When a plan's PBM is incentivized to managing future price increases, prescription drug cost trend tends to improve.... Particularly for plan sponsors that signed their PBM contract years ago, it's worth exploring options, because drug pricing dynamics and PBM pricing models have recently changed dramatically."  MORE >>