Senate tax package includes direct primary care provision

By Allison Bell - The Senate put a direct primary care provision back in the One Big Beautiful Bill Act tax package. A full-text version posted Saturday by Sen. Lindsey Graham, R-S.C., the chairman of the Senate Budget Committee, includes direct primary care provision. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Direct Primary Care Provision Added to Senate Tax Package: The Senate’s tax package now includes a provision allowing Health Savings Account (HSA) holders to use their funds to pay for direct primary care (DPC) membership fees—capped at $150 per month for individuals and $300 per month for households. This marks a notable change from earlier committee drafts, which excluded the DPC provision, and signals growing legislative interest in alternative healthcare payment models.

2. Senate Passed the Package by Tie-Breaking Vote: The Senate approved the tax package in a 50-50 split vote, with Vice President JD Vance casting the tie-breaking vote in favor. The measure saw unified opposition from all voting Democrats and independents, joined by three Republicans—Susan Collins, Rand Paul, and Thom Tillis—highlighting the package's partisan and contentious nature.

3. Broader Tax and Policy Changes Still Unresolved: The One Big Beautiful Bill Act (OBBBA) aims to extend provisions from the 2017 Tax Cuts and Jobs Act and introduce new tax breaks, including for tips and overtime income, while offsetting costs through tighter eligibility rules for Medicaid, Medicare, and ACA benefits. Differences between the Senate and House versions remain, especially around health account provisions and AI regulation, setting the stage for further negotiation and potential amendments before final passage.

The AI Advantage In Group And Voluntary Benefits

By Denise Garth and Mike De Waal - Artificial intelligence (AI) has the potential to revolutionize the group and voluntary benefits industry, particularly during peak business periods when human resources are stretched extremely thin and with a growing number of generational segments as employees who have different needs. Read Full Article…

HVBA Article Summary

1. AI Enhances Plan Design and Sales Strategy: Group and voluntary benefits insurers can leverage AI recommendation engines to analyze historical sales data and generate optimized, alternate plan designs tailored to specific client attributes such as size, industry, and location. This empowers sales and underwriting teams with data-backed benchmarks, supports more effective upselling and cross-selling, reduces quote turnaround times, and ultimately drives increased revenue and stronger client relationships.

2. AI Streamlines Underwriting and Operations: AI helps optimize underwriting efficiency by intelligently assigning quotes based on each underwriter’s capacity, expertise, and historical performance. It also identifies high-probability opportunities to improve close ratios. On the operations side, AI-powered tools use technologies like OCR and NLP to extract and structure unformatted data from broker communications and RFPs, significantly reducing manual effort, minimizing errors, and accelerating the quoting process.

3. AI-Powered Chatbots Unlock New Revenue and Engagement: Modern AI chatbots and virtual assistants provide immediate, personalized support to plan members, answering questions, guiding enrollment, and recommending relevant voluntary benefits based on individual data. These tools go beyond reactive help by proactively engaging users with timely nudges and suggestions. Case studies like Sun Life’s “Ella” demonstrate how AI-driven digital assistants can dramatically improve customer experience and drive significant increases in coverage purchases.

How ICHRAs put downward pressure on health plan costs

By Ben Light - Individual coverage health reimbursement arrangements have remained a hot topic since their inception in 2020, sparking enthusiasm, debate and most importantly, adoption. Although many acknowledge that ICHRAs can significantly cut costs — often by 20% or more — some skeptics argue that they merely shifts expenses rather than driving meaningful change. Read Full Article…

HVBA Article Summary

1. ICHRAs are improving the insurance risk pool and stabilizing premiums: A significant shift toward younger, healthier individuals (ages 18–44) enrolling in ICHRAs is helping to rebalance the individual insurance market. This healthier risk pool is already leading to year-over-year premium reductions, making coverage more affordable and sustainable for everyone.

2. Greater choice is empowering employees and transforming insurer behavior: By allowing employees to choose their own health plans, ICHRAs are introducing real competition among carriers. This consumer-driven model is pressuring insurers to improve service, enhance transparency, and offer better value — a major departure from the limited, employer-selected options in traditional group plans.

3. ICHRAs promote better coverage fit and broader access: Employees are selecting plans that align more closely with their actual health needs and budgets, with nearly 70% choosing gold or silver-tier coverage. At the same time, rising dependent enrollment is expanding access to ACA-compliant insurance for families, while insurers are developing tailored plans for high-risk populations — all without overburdening employers.

Tiara Yachts v. BCBS Michigan: A Cautionary Tale

By Jon Jablon, Esq. - When it comes to self-funded health plans, fiduciary duties often tend to lurk in the background – acknowledged and respected, but not always fully understood. The recent Sixth Circuit decision in Tiara Yachts, Inc. v. Blue Cross Blue Shield of Michigan brings those duties into sharp focus, offering a valuable lesson for TPAs, brokers, and plan sponsors. Read Full Article…

HVBA Article Summary

1. Fiduciary Status Defined by Function, Not Labels: The Sixth Circuit concluded that BCBSM acted as a fiduciary under ERISA because it exercised discretionary control over plan assets, particularly in how it processed and paid claims. This decision reinforces the principle that fiduciary responsibilities are determined by the actual functions and authority a party has over plan management – not by their title or what’s stated in a contract.

2. Conflict of Interest in Error Recovery Practices: BCBSM allegedly applied a workaround called “flip logic” that led to excessive reimbursements on certain out-of-network claims. It then initiated a Shared Savings Program to “recover” those overpayments, charging a 30% fee in the process. The court found this deeply problematic, suggesting that charging to fix one’s own systemic mistakes could indicate self-dealing and breach of fiduciary duty, especially when the errors benefit the administrator financially.

3. Importance of Transparency and Structural Safeguards: The case highlights the need for clear boundaries and independent oversight when administering self-funded plans, particularly in high-risk areas like overpayment recovery. Utilizing third-party vendors for such functions can mitigate potential conflicts of interest, provide auditability, and demonstrate a good-faith effort to uphold fiduciary responsibilities—critical in avoiding both the appearance and reality of impropriety.

Benefits Think: 3 fixes to eliminate health plan waste and boost ROI

By Bill Frack - Healthcare costs are surging, and your clients are feeling the pressure. Employers are bracing for a 9% increase this year – the sharpest rise in a decade. GLP-1s and specialty drugs are driving pharmacy spend through the roof. Chronic conditions are projected to cost U.S. businesses $2 trillion in medical expenses and $794 billion in lost productivity by 2030. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Employers Struggling with Complex Benefits Ecosystems: A majority of large employers now use 12 or more point solutions to manage healthcare, well-being, and pharmacy benefits, creating a fragmented and costly system. This complexity has led 53% of employers to plan platform consolidation in 2025, highlighting growing demand for streamlined, cost-effective benefits management.

2. Consultants Positioned to Drive Efficiency and Savings: Benefits consultants are encouraged to take a leadership role by identifying and addressing financial leakages in employer health plans—such as underpayments, contract mismanagement, and data mismatches. These inefficiencies are widespread and present clear opportunities for consultants to demonstrate value and reduce waste.

3. Simplification and Automation as Strategic Imperatives: The current reliance on manual reporting and disconnected vendor tools is proving unsustainable. Integrating automation and centralized oversight enables faster insights, improved vendor accountability, and smarter decision-making—positioning consultants to deliver both strategic guidance and measurable results.

Only 8% of GLP-1 users stay on treatment after 3 years: Study

By Jakob Emerson - After three years, only about 1 in 12 individuals taking GLP-1s to treat obesity remained on the therapy, according to a Prime Therapeutics study published on June 25. Prime is owned by 19 Blue Cross and Blue Shield plans and manages pharmacy benefits for about 73 million people. Read Full Article…

HVBA Article Summary

1. Long-Term GLP-1 Use Is Low: After three years, only 8.1% of individuals continued GLP-1 therapy, highlighting significant drop-off over time. Among different medications, weekly Wegovy users had the highest long-term persistence at 14.3%, while daily Victoza users had the lowest at just 2.5%.

2. Medication Switching and Adherence Challenges: Throughout the three-year period, 37.5% of members switched from one GLP-1 drug to another, indicating frequent changes in treatment. Additionally, only 12.5% of users maintained regular medication use for at least 80% of the time, pointing to overall low adherence.

3. Improved Short-Term Persistence Driven by Supply and Support: One-year persistence rates saw a marked improvement by 2024, with both Wegovy and Zepbound reaching over 62%. This increase is largely attributed to the resolution of supply chain issues, along with better dose escalation protocols, side-effect management, and expanded support through care and lifestyle programs.

CVS PBM Hit With $95M Judgment For Overbilling Medicare

By P.J. D’Annunzio - A Pennsylvania federal judge on Wednesday ruled that CVS's pharmacy benefits manager owes the government $95 million for overbilling Medicare Part D-sponsored drugs, leaving the door open for the amount to be tripled later. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Judge Finds CVS Caremark Liable for Inflated Drug Costs: Chief U.S. District Judge Mitchell S. Goldberg determined that CVS Caremark Corp. submitted inflated reimbursement data for Medicare Part D drugs, leading the Centers for Medicare & Medicaid Services (CMS) to over-subsidize drug costs. The court found that damages were proven with reasonable certainty, although a final decision on potential treble damages has been deferred pending further briefing.

2. Whistleblower’s Claims Partially Upheld: Whistleblower Sarah Behnke successfully demonstrated that Caremark’s pricing practices with Rite Aid and Walgreens resulted in financial harm to the government. However, the court did not find sufficient evidence to support her broader claims involving CVS Pharmacy or CVS Health Corporation, thereby limiting the entities held liable in the case.

3. Government Interest Despite Non-Intervention: While the federal government did not formally intervene in the lawsuit, it filed a statement of interest reinforcing its concern about inflated Medicare drug prices and the accuracy of cost reporting to CMS. Judge Goldberg acknowledged that the government is closely monitoring such practices, highlighting ongoing regulatory attention toward pharmacy benefit managers and Medicare program integrity.