Merry Christmas! From - the 5th Circuit Court of Appeals

By Chris Deacon – A Merry Christmas gift for every employer, fiduciary, and benefits leader. Not necessarily a happy holiday for Aetna. Most major health plan cases this year have arrived with noise, fanfare and some applause (or boos). Certainly headlines. Commentary. Industry hand-wringing. But not this one. Read Full Article...

HVBA Article Summary

1. Significant Legal Victory for Plan Sponsors: The Fifth Circuit’s decision in Aramark Services v. Aetna represents a pivotal moment for self-funded employers by affirming their right to pursue legal action against third-party administrators (TPAs) in court, rather than being forced into private arbitration. This outcome is expected to strengthen transparency and public accountability, potentially changing the way disputes over health plan administration are resolved across the country.

2. Allegations of Misconduct Against Aetna: Aramark, a major employer with a self-funded health plan, filed suit against Aetna alleging several years of administrative misconduct. The claims include paying invalid or fraudulent bills, retaining hidden fees, mishandling subrogation processes, and improperly managing plan assets. Instead of directly addressing these allegations, Aetna sought to move the case to private arbitration based on a contract clause—a strategy the court ultimately rejected.

3. Implications for Health Plan Governance: This ruling could have far-reaching consequences for how employers manage their relationships with TPAs. By rejecting the move to arbitration, the court reinforced the role of public litigation in setting legal standards and deterring misconduct. Benefits leaders, fiduciaries, consultants, and policymakers may now revisit how service agreements are structured and enforced, with a renewed focus on transparency, legal recourse, and plan oversight.

2026 Outlook: Uncertainty clouds the future on the ACA exchanges

By Paige Minemyer - The future of these tax credits and the impact they could have on enrollment was a headliner in healthcare in the back half of the year, and experts warn that it’s unclear what comes next. Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy, told Fierce Healthcare that with an extension almost certainly off the table, it’s going to force tough decisions for consumers now even if Congress acts in early 2026. Read Full Article…

HVBA Article Summary

1. Uncertainty Around Health Subsidies Could Drive Up Uninsurance Rates and Premiums: The expiration of enhanced tax credits is projected to cause a significant spike in healthcare premiums—estimated at an average increase of 114%, or over $1,000 per person annually, according to KFF. This cost surge may lead around 4 million people to lose their insurance coverage in 2026. Younger and healthier individuals, who are typically more price-sensitive, may opt to forgo coverage entirely, leaving insurance pools with a higher proportion of older or less healthy individuals. This imbalance could further increase premiums in 2027, amplifying the affordability crisis.

2. Legislative Gridlock Leaves Subsidy Extensions in Limbo: Efforts in both the House and Senate to extend or replace the subsidies stalled before the holiday recess, with no agreement reached. While some legislators previously indicated openness to a bipartisan solution, shifting political rhetoric—particularly framing the subsidies as handouts to insurance companies rather than support for consumers—has eroded momentum. With lawmakers not returning until early 2026, the window to implement meaningful reforms before the cost increases take effect is rapidly closing.

3. Market Instability and Alternative Solutions Are Emerging: Health insurers are already preparing for a more volatile individual insurance market in 2026, anticipating the exit of lower-risk consumers. This could destabilize the market and drive premiums even higher. Some experts see potential in Individual Coverage Health Reimbursement Arrangements (ICHRAs), which allow employers to subsidize employees’ purchases of individual plans. This model could help draw younger, employed individuals back into the market, improving the risk pool and potentially mitigating future rate hikes and instability across the exchanges.

CMS proposes new price transparency rules

By Madeline Ashley - President Donald Trump’s administration proposed significant updates Dec. 19 to healthcare price transparency rules to help make costs more “clear, accurate and actionable for Americans.” The proposal, shared by CMS, in partnership with the labor and the treasury departments, builds on rules established during President Trump’s first term. Read Full Article…

HVBA Article Summary

1. Improved Transparency in Healthcare Pricing: The proposed rule from the Department of Health and Human Services seeks to enhance public access to clear and usable healthcare pricing information. It builds upon the 2020 Transparency in Coverage rules by addressing previous challenges in data navigation and usability. The goal is to allow individuals and families to make more informed healthcare decisions and increase system accountability through easier access to cost details.

2. Enhanced Tools and Reporting Requirements: The proposal introduces significant updates to how insurers and health plans provide pricing data. This includes simplifying file structures, reducing redundancy, and cutting reporting frequency from monthly to quarterly. Additionally, price comparison tools will be improved to ensure consumers receive detailed and consistent cost-sharing information through multiple channels, such as online, print, and phone support — helping them better understand potential financial obligations.

3. Ongoing Policy Development and Public Input: While the new rule represents a major step toward transparency, it does not yet include changes to prescription drug price disclosures, which are expected to be addressed separately in the future. The proposal is open for a 60-day public comment period, ending February 21, allowing stakeholders — including patients, insurers, and providers — to give feedback and influence the final policy direction.

Major drug pricing regulation moves forward

By Caitlin Owens – A regulation with potentially major implications for the pharmaceutical industry has cleared its review, teeing it up for imminent proposal should the Trump administration decide to move forward. Why it matters: The regulation, which appears to tie what the U.S. pays for some drugs to the prices in other countries, would be the administration's most aggressive step yet to lower U.S. drug prices. Read Full Article...

HVBA Article Summary

1. Proposed GLOBE Model Regulation Signals Major Policy Shift: The Biden administration’s proposed regulation, known as the "Global Benchmark for Efficient Drug Pricing (GLOBE) Model," has completed its review process and is labeled “economically significant,” suggesting it could lead to far-reaching changes in drug pricing policy. While the exact framework remains unclear, many analysts and lobbyists speculate it may mirror a prior Trump-era effort that aimed to link Medicare Part B drug prices to those in other countries.

2. Potential Financial Impact on Manufacturers: If enacted, the GLOBE Model could have substantial financial implications for pharmaceutical manufacturers, potentially lowering the reimbursement rates they receive from government programs. This mirrors concerns raised by the industry during previous proposals to implement most-favored-nation pricing strategies, which sought to curb U.S. drug costs by referencing lower international prices.

3. Ongoing Industry and Government Negotiations: The proposed rule comes in the context of ongoing negotiations between the White House and pharmaceutical companies. These talks have resulted in pricing agreements that include Medicaid concessions, commitments to align U.S. launch prices with international levels, and participation in government-run direct-to-consumer drug platforms. While these deals are significant, the administration has not dismissed the possibility of applying broader industry-wide regulations, keeping the potential for sweeping changes on the table.

Benefits Think: ICHRAs offer a new approach to health benefits for employers

By Whitney Stidom - Most Americans get their health insurance through an employer, but that system is becoming increasingly costly, with premiums up 25% in the last five years. In fact, a recent survey of small to mid-sized business owners and managers found 75% are worried that within three years their group health plan will be too expensive to offer. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. ICHRA Adoption Is Rapidly Increasing: Individual Coverage Health Reimbursement Arrangements (ICHRAs) are gaining momentum as an alternative to traditional group health insurance, with adoption up 52% in the past year. This model, introduced under the Trump administration and sustained through the Biden years, allows employers to offer defined contributions toward employee-selected health plans, mirroring the shift from pensions to 401(k)s in retirement benefits.

2. Businesses Express High Demand for Change: A recent survey of companies with 500 or fewer employees revealed that 93% of business owners and managers believe they need a new health benefit solution, and 92% feel the issue is being overlooked by policymakers. Despite limited legislative progress, 75% of respondents view the ICHRA model as a favorable alternative to current group plans.

3. Cost Control and Flexibility Drive Appeal: In some states, premiums for individual health coverage can be 30% to 50% lower than group plans on a per-person basis, making ICHRAs especially attractive for cost-conscious employers. While federal tax incentives are still under discussion, some businesses are already making the switch to stabilize expenses. Employers are advised to assess local market conditions and partner with experienced ICHRA administrators to support smooth implementation and employee education.

More GLP-1s aim to enter US market

By Paige Twenter - Novo Nordisk is seeking FDA approval for an experimental obesity shot, CagriSema (cagrilintide and semaglutide), according to a Dec. 18 news release from the Denmark-based drugmaker. CagriSema is a weekly injection of semaglutide, a GLP-1, and cagrilintide, a long-acting amylin analogue. If approved, the drug would be the first injectable GLP-1 and amylin analogue combination treatment. Read Full Article…

HVBA Article Summary

1. CagriSema Demonstrates Notable Weight Loss in Phase 3 Trial: In a phase 3 clinical trial involving 3,417 adults with obesity or overweight and at least one obesity-related health condition, participants who took Novo Nordisk’s experimental drug CagriSema achieved an average weight loss of 20.4% after 68 weeks. By contrast, those in the placebo group experienced an average weight loss of only 3%. Novo Nordisk announced that it anticipates FDA review of the drug in 2026, potentially expanding its portfolio in the anti-obesity drug market.

2. Eli Lilly Reports Encouraging Results for Multiple GLP-1-Based Treatments: Eli Lilly shared positive updates on two experimental drugs. In a phase 3 trial, orforglipron, a daily oral GLP-1 pill, helped participants maintain weight loss after initially using injectable GLP-1 therapies like Wegovy or Zepbound. Weight regain was modest (about 2–11 pounds, depending on prior treatment). Additionally, retatrutide, a triple-hormone receptor agonist, resulted in an average 28.7% weight loss and reduced pain in adults with obesity and knee osteoarthritis over a 68-week trial. The company is pursuing regulatory approval for orforglipron and expects more retatrutide data in 2026.

3. Industry Expansion and Safety Research Around GLP-1 Drugs: Pfizer is making strategic moves into the GLP-1 drug market with a $150 million upfront deal with YaoPharma for a phase 1 small-molecule GLP-1 receptor agonist (YP05002), and a planned acquisition of Metsera, a clinical-stage obesity drugmaker, in a deal that could exceed $10 billion. Meanwhile, a Harvard University study analyzing nearly 100,000 participants across 48 trials found that GLP-1 drugs had little or no effect on the risk of several obesity-related cancers, including thyroid, breast, and pancreatic cancers. However, the researchers noted less certainty about the drugs' impact on nine other cancer types.

EBN's best of 2025: How employers are evolving wellness benefits

By Mike Bassett – Employee mental health and wellness have moved from a workplace "nice to have" to a core business priority, and that shift is only accelerating as organizations look toward 2026. For many workers, stress, burnout and anxiety are no longer episodic challenges but persistent realities that directly affect engagement, productivity and retention. Benefit leaders are increasingly on the front lines of this issue, tasked with translating organizational commitment into meaningful, accessible support. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Mental Health Benefits Must Evolve Beyond Traditional Programs: While employee assistance programs (EAPs) continue to play an important role, they are no longer sufficient on their own. Employees increasingly expect mental health benefits that are easy to access, culturally relevant, and connected to the broader benefits ecosystem, including medical and behavioral health coverage, financial wellness resources, flexibility, and time-off policies. This shift reflects changing workforce expectations and a growing emphasis on holistic well-being.

2. Proactive, Personalized Strategies Are Gaining Importance: As 2026 approaches, leading mental health strategies are becoming more data-driven and individualized. Employers are using digital mental health tools, analytics, and early intervention programs to identify needs sooner and reduce barriers to care. At the same time, organizations are placing greater emphasis on manager training, clear communication, and workplace cultures that normalize mental health conversations rather than stigmatizing them.

3. Holistic Mental Health Support Is Both a Human and Strategic Priority: Investing in inclusive, comprehensive wellness programs is increasingly seen as essential to building resilient, adaptable workforces. Organizations that embed mental health support into the overall employee experience—rather than treating it as a standalone benefit—are better positioned to support employees through ongoing change. For benefits leaders, this represents both a challenge and an opportunity to make mental health a foundational element of workplace strategy.