Payers seek double-digit exchange rate hikes for 2026

By Jakob Emerson - Many insurers are asking for double-digit rate increases in 2026 for the individual and small group exchange markets as they face a potential expiration of enhanced premium tax credits and rising costs. Read Full Article…

HVBA Article Summary

1. Significant 2026 Rate Hikes Across States: Health insurers in multiple states are proposing double-digit premium increases for 2026 in the individual and small group markets. Washington leads with a 21.2% average increase for individual plans, followed by Vermont’s BlueCross BlueShield requesting a 23.3% hike, and New York small group rates rising 24%.

2. Variation Between Individual and Small Group Markets: While individual plans generally see higher proposed increases, the small group market varies more by state. For example, Maryland proposes only a 5.5% increase for small groups compared to 17.1% for individuals, whereas New York shows the opposite trend with a steeper small group increase.

3. Regional Differences Reflect Diverse Cost Pressures: Average proposed increases vary significantly by state, from a low of 9.7% for Oregon individual plans to highs exceeding 20% in Washington and Vermont. These discrepancies may reflect differing regional medical cost trends, insurer competition, and regulatory environments.

What Health Care Lawyers and Professionals Need to Know About Emerging Employee Benefit Issues

By Tzvia Feiertag, Heather Stone Fletcher, Samuel C. Nolan, Jeb Gerth, Christine Burke Worthen, and Karen Mandelbaum - Employee benefits compliance has many traps for the unwary and is ever evolving. Below, we have provided a primer on current issues of importance in the employee benefits area to help in-house attorneys identify potential risks, mitigate them, and know when to call an outside ERISA lawyer. Read Full Article…

HVBA Article Summary

1. Self-Funded Health Plans Require Robust Governance and Documentation: Employers sponsoring self-funded health plans face growing legal, fiduciary, and compliance risks due to intensified DOL audits, litigation trends, and regulatory scrutiny. Establishing a formal benefits committee—similar to those used for retirement plans—can help oversee plan operations, reinforce fiduciary processes, document decision-making, and mitigate liability exposure for corporate boards.

2. Regulatory Uncertainty and Litigation Risk Remain High in Mental Health Parity and PBM Oversight: Despite a recent pause on enforcing certain rules under the Mental Health Parity law, self-funded plans must continue to maintain and update Non-Quantitative Treatment Limitation (NQTL) analyses due to ongoing DOL audits and potential lawsuits. Meanwhile, state-level PBM laws—like Florida’s—are testing ERISA preemption boundaries by requesting detailed prescription drug data, raising compliance challenges related to both federal law and HIPAA privacy protections.

3. Cybersecurity and Wellness Compliance Are Now Critical Priorities for All ERISA Plans: The DOL has confirmed its cybersecurity guidance applies to all ERISA-regulated plans—not just retirement plans—amid escalating threats to health data. Employers must ensure their vendors, systems, and internal practices meet DOL cybersecurity expectations. Additionally, wellness programs tied to health outcomes must clearly communicate and administer reasonable alternative standards to avoid legal challenges tied to HIPAA nondiscrimination rules.

Employers' $1M health claim rate rises 29%

By Allison Bell - Why did the cost of providing stop-loss insurance — insurance for employers' self-insured health plans — spike so hard last year One reason is that the number of huge claims increased. A lot. Sun Life U.S., a major stop-loss provider, says the employers that used its coverage in 2024 received 221 claims for $1 million or more per 1 million covered employees. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Surge in High-Cost Claims: Sun Life U.S. reported a 29% increase in $1 million+ claims in 2024, with 221 such claims per 1 million covered employees. Claims of $3 million or more rose 47%, with the most expensive claim hitting $12.7 million—15% higher than the prior year’s peak.

2. Drivers of Jumbo Claims: Rising labor and supply costs, government cost-shifting, and the emergence of expensive treatments like gene therapy (e.g., $6.8M for Elevidys) are fueling the spike in ultra-high-cost claims. Many of these cases involve prolonged hospital stays and complex surgeries.

3. Emphasis on Early Intervention: Sun Life underscores the importance of preventive care and early detection as key defenses against catastrophic claims. The company is expanding condition-specific programs and care navigation to support employers using self-insurance paired with stop-loss coverage.

Case study of attempts at drug-pricing reforms in Ohio shows promise and peril for the Trump administration and Congress

By Darrel Rowland - Phones ring all the time across a newsroom. But when one of my colleagues answered a call by saying, “Good morning, governor,” all of us sitting near her quickly took notice. Just a few weeks after taking office in 2019, Ohio Gov. Mike DeWine had been reading the dozens of stories our team at The Columbus Dispatch had written on how little-known pharmacy benefit managers were bleeding the state. Read Full Article…

HVBA Article Summary

1. Ohio’s Medicaid PBM Reform Saved Money and Boosted Transparency, but Fell Short of Initial Projections: Ohio replaced multiple private pharmacy benefit managers (PBMs) with a single, state-overseen PBM (Gainwell) to reduce overcharging and increase oversight in its Medicaid drug program. While the reform saved approximately $70 million annually—half of the projected amount—it also delivered broader benefits, including increased pharmacy reimbursement rates and improved patient access to medications.

2. Operational Challenges and Governance Tensions Have Complicated Implementation: Despite progress, the single-PBM model faced early execution issues, such as delays in processing prior authorizations and late compliance reporting, which resulted in state-imposed penalties. Additionally, tensions between state Medicaid officials and the legislature over oversight responsibilities have fueled skepticism about transparency and accountability.

3. Ohio’s Experience Offers Lessons for National Drug Pricing Reform Amid Ongoing Legal and Political Headwinds: Ohio’s aggressive stance on PBM regulation has influenced broader national policy discussions, serving as both a model and cautionary tale. While the state’s approach brought attention to PBM practices and demonstrated potential savings, continued legal challenges, incomplete savings, and political resistance underscore the complexities of reforming Medicaid drug pricing at both the state and federal levels.

Benefits Think: ICHRAs empower employees to lead healthier lives

By Lisa Collins - Change brings with it curiosity, skepticism discomfort, but ultimately, still carries a reputation for being a positive force. The individual coverage health reimbursement arrangement known as ICHRA has opened an entirely new avenue for employers looking to offer healthcare to their teams. In spite of this novel approach, it has been met with reluctance from brokers and advisers for representing what they fear is too radical a departure from a group health plan. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. ICHRA offers flexible, cost-effective healthcare solutions for modern workforces: Over five years, the Individual Coverage Health Reimbursement Arrangement (ICHRA) has become a strategic tool for employers and brokers, enabling tailored benefits for diverse and remote teams while helping businesses control costs—especially in high medical loss ratio or self-funded scenarios.

2. Successful implementation requires thoughtful planning and communication: Employers must set individual contribution amounts, establish a reimbursement system, and clearly communicate the value of ICHRA to employees. The transition can present administrative challenges, but platforms and broker support can simplify the process and guide both employers and employees.

3. ICHRA empowers employee choice and modernizes benefits strategy: By moving away from traditional one-size-fits-all plans, ICHRA allows employees to select individual health plans that best meet their needs. This approach aligns with evolving expectations around personalization and flexibility in healthcare, offering brokers a valuable opportunity to modernize client offerings while maintaining ACA compliance.

Why CVS, Express Scripts Are Suing Over the Arkansas PBM Law

By Marissa Plescia - There have been several recent efforts to crack down on pharmacy benefit managers, from bills in Congress to an investigation (Opens in a new window) by the Federal Trade Commission. But the state of Arkansas has been the one to actually take definitive action. Read Full Article…

HVBA Article Summary

1. Arkansas Targets PBM Ownership: Governor Sarah Huckabee Sanders signed a law banning pharmacy benefit managers (PBMs) from owning or operating pharmacies in the state starting January 1, 2026, aiming to curb anti-competitive practices and protect local pharmacies from domination by national PBMs like CVS Caremark, Express Scripts, and Optum Rx.

2. Lawsuits Claim Unfair Targeting: CVS and Express Scripts are suing to overturn the law, arguing it is unconstitutional, discriminates against out-of-state businesses, and unfairly exempts Arkansas-based Walmart. They warn the law could shutter pharmacies, eliminate jobs, and reduce access to care for thousands of Arkansans.

3. National Implications and Pushback: The law has sparked national interest, with states like Vermont and New York considering similar measures. While PBMs claim the law violates interstate commerce protections, supporters—including pharmacists’ groups—praise it as a bold step to dismantle vertically integrated monopolies and prioritize patient access.

Regeneron's Weight-loss Drug Helps Patients on Wegovy Preserve Muscle

By Mariam Sunny and Bhanvi Satja - Regeneron said on Monday its experimental drug helped patients preserve up to 51% of lean mass and lose more fat when used in combination with Novo Nordisk's popular obesity drug Wegovy in a mid-stage trial. In the 599-patient study, those on Wegovy alone lost about 7.9 pounds of muscle, while those on a combination of Regeneron's trevogrumab and Wegovy lost up to 4.2 pounds. Read Full Article…

HVBA Article Summary

1. Regeneron’s Muscle-Preserving Obesity Drug Shows Early Promise: In combination with Wegovy, Regeneron's antibody trevogrumab helped patients lose up to 11.3% of their body weight, slightly more than Wegovy alone (10.4%), with the triple therapy reaching 13.2%. These early results position Regeneron as a strong contender in the $150 billion weight-loss drug market, which is now focusing on therapies that preserve muscle mass.

2. Muscle Loss Remains a Key Challenge in Weight-Loss Therapies: Market leaders Novo Nordisk and Eli Lilly face scrutiny as their obesity drugs also cause muscle loss. Regeneron and others (e.g., Veru and Scholar Rock) are working to counter this with new therapies, but the FDA has yet to define clear approval standards for drugs focused on muscle preservation.

3. Safety and Regulatory Uncertainty Loom Over Future Development: While Regeneron's drug combinations show promising weight-loss benefits, the high dropout rate (28%) and two patient deaths in the triple therapy group raise safety concerns. Analysts stress that clean safety data and clearer FDA guidance will be critical hurdles for regulatory approval and market success.