Search the News Archive

The Specialty Drug Pipeline: Independent Prior Authorization Will Define 2026

"As the drug pipeline expands, [prior authorization (PA)] has evolved from a transactional checkpoint into a mechanism of clinical governance. Yet, when pharmacy benefit managers (PBMs) oversee both utilization management and dispensing, financial incentives can influence coverage decisions. This overlap has prompted closer attention to how the PA function can maintain neutrality and transparency across stakeholders."

2026 PCORI Fee Amounts Announced

"For plan years ending January 2026 through September 2026, PCORI fees are not due until July 31, 2027. This breaks down more specifically as follows: $3.47 per covered life for plan years ending in January through September of 2025 ... $3.84 per covered life for plan years ending in October through December of 2025  ... $3.84 per covered life for plan years ending January through September of 2026."

State of Illinois Set to Require Health Coverage for Dependent Parents in 2026

"Set to go into effect on January 1, 2026, Illinois House Bill 5258 will ... mandate that fully insured health plans in the state of Illinois include insurance coverage for ... both parents and stepparents of an insured individual ... if the parent or stepparent lives within the service area of the accident and health insurance policy and meets the definition of a 'qualifying relative' under 26 U.S. Code Section 152(d)."

ACA Affordability Rates Announced for 2026

"The 'sledgehammer' penalty applies when an ALE fails to offer Minimum Essential Coverage (MEC) to at least 95% of its Full-Time Equivalent employees (FTEs) as defined by the ACA in any given calendar month. The penalty is $278.33 per month ($3,340 per year) and is multiplied by all FTEs (minus the first 30).... Coverage is considered affordable as per the Section 4980H(b) 'tack hammer' penalty if the required employee contribution satisfies at least one of the three safe harbors. The 2026 'tack hammer' penalty is levied at $417.50 per month ($5,010 per year) for each applicable FTE."

Implementing Voluntary Benefits to Reduce Employee Stress

"[E]mployers should measure the success of the programs every 12 to 24 months. Employers can conduct surveys to test employee awareness of, understanding of, and satisfaction with the programs. Companies can also benchmark their benefit portfolios against those offered by industry peers. Finally, employers can examine participation rates among employees to determine if they are at, above, or below industry norms with regard to re-enrollment and persistency."

The Continued Rise of Voluntary Benefits

"the compound annual growth rate (CAGR) for Supplemental Health premium is expected to exceed 10% through 2030 – a stark contrast to the CAGR anticipated for life and disability products. If these forecasts are correct, it will make Supplemental Accident and Health products the fastest growing non-medical premium volume in the Health and Welfare space."

2025 CHIP Model Notice Released by DOL

"[CHIPRA] implemented an annual notice requirement for any employers that maintain a group health plan that covers participants who reside in a state that provides any type of premium assistance subsidies under a CHIP or Medicaid plan. The notice obligation does not depend on the employer's physical location(s) and is based instead on where the plan's eligible individuals reside. The DOL makes annual updates to the CHIP Notice for states offering premium assistance subsidies[.]"

How Self-Funded Health Plans Are Leveraging Direct Contracting

"Direct contracting ... provides the cost control of [reference based pricing (RBP)] without the associated member disruption. In this model, the employer negotiates a fixed price for care with the provider and pays the claim cost directly from health plan funds. Most direct contracts use a bundled arrangement, where the entire episode of care is billed as one cost, rather than multiple billing codes in the traditional fee-for-service model."

Captives Provide Employers with New Opportunities for Employee Benefits

"Captives are alternative risk management programs that offer several advantages for well-qualified employers, especially in the areas of cost savings, design flexibility, and claims management. While this risk solution can present new opportunities, it also comes with its own set of challenges and questions that management teams need to address."

Arkansas Rule 128 Compliance Guide: Pharmacy Compensation Reporting for Group Health Plans

"A group health plan or insurance carrier subject to Rule 128 must file an annual written report to the AID that describes each pharmacy compensation data for the then applicable plan year.... [Bulletin #18-2024] permits a third-party administrator or PBM of a self-funded group health plan to file the data or report on behalf of the group health plan.... The Bulletin expressly states that the Rule applies to self-funded employer health plans and self-funded government health plans. However, there is at least an argument that the Rule is preempted by ERISA."