More Than 50 Health Plans Commit to Simplifying Prior Authorization

By Marissa Plescia - Dozens of health insurers have made a series of commitments to improve and reduce prior authorization, payer advocacy organization AHIP announced on Monday. The practice is often a point of contention with providers, who argue that it adds administrative burden and delays care. Read Full Article…

HVBA Article Summary

1. Major insurers commit to streamlining prior authorization: A total of 53 insurers, including UnitedHealthcare, Aetna, Cigna, and several regional plans, have voluntarily pledged to simplify and modernize prior authorization processes by 2027. The changes include standardizing electronic submissions, reducing prior authorization requirements, and improving communication.

2. Reforms aim to balance patient care and administrative efficiency: The commitments focus on improving continuity of care, increasing transparency in decision-making, and enabling real-time authorization responses. Insurers state these reforms are intended to reduce administrative burdens and enhance the patient experience without eliminating prior authorization entirely.

3. Stakeholders express cautious optimism but emphasize accountability: While the reforms are widely supported, including by the American Medical Association, there is concern over implementation specifics. Medical professionals and industry leaders stress the need for measurable results, greater transparency, and prompt action to ensure the changes bring real, timely improvements for patients and providers.

CMS finalizes rule aimed at 'improper' sign-ups on the ACA exchanges

By Paige Minemyer - The Centers for Medicare & Medicaid Services (CMS) has finalized a rule that it says will address "the surge of improper enrollments" on Affordable Care Act (ACA) exchanges as well as take on wasteful spending. The agency said late Friday that there are likely millions of people who were improperly enrolled in ACA exchange plans. Read Full Article…

HVBA Article Summary

1. Improper ACA Enrollments and Fraud Concerns: The Centers for Medicare & Medicaid Services (CMS), citing a study from the Paragon Health Institute, estimates that up to 5 million people may have been improperly enrolled in ACA plans in 2024, potentially costing taxpayers $20 billion. The agency attributes this to weakened verification procedures and expanded premium subsidies.

2. New Rules to Tighten Eligibility and Enrollment: CMS is implementing a final rule aimed at reducing fraud, including ending certain special enrollment periods, requiring more rigorous income and eligibility verifications, shortening the open enrollment period to December 31, and reducing automatic subsidy payments without updated eligibility confirmation.

3. Policy and Coverage Adjustments: The final rule includes provisions to exclude federal subsidies for some gender-affirming procedures and reinstates a policy that bars DACA recipients from ACA exchange coverage. Some of these changes are set to expire after the 2026 plan year, pending review of their effectiveness.

Blue Cross and Blue Shield carrier employer plan administration costs climb

By Allison Bell - Blue Cross and Blue Shield companies were much tougher on administrative costs at the self-insured plans they ran in 2024 than at employers' fully insured plans. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Administrative cost growth was moderate for self-insured plans and higher for fully insured plans: According to data from Sherlock Co., median administrative costs increased by 5% for self-insured plans, reaching $35.31 per member per month (PMPM), while fully insured plans experienced a larger increase of 10.7%, bringing their median costs to $64.82 PMPM. This indicates a notable cost difference in administrative spending between the two plan types.

2. Self-insured plans remain the dominant model in employer coverage: Sherlock’s data shows that 61.5% of enrollees in employer-sponsored health plans are in self-insured arrangements. This highlights the continued preference among employers for self-insured models, which may offer more flexibility and potentially lower overall costs compared to fully insured plans.

3. Lower administrative costs in employer self-insured plans are attributed to healthier enrollees and purchasing efficiencies: Analysts at Sherlock attribute the relatively low administrative expenses—6.4% of premium equivalents in 2024—to the generally healthier population covered by employer plans and to cost-saving advantages from group purchasing strategies, which reduce distribution and other administrative costs.

Benefits Think: Creating benefits for multigenerational workforces

By Cole Harris - Today's workforce is made up of employees spanning several generations. Each group — from baby boomers and Generation X to millennials and Generation Z — brings with them distinct needs, expectations and priorities regarding employee benefits. For benefit advisers, this diversity presents both a challenge and opportunity when it comes to helping employer clients design benefit packages. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Tailored, Flexible Benefits Are Essential: A one-size-fits-all approach no longer suffices in today's multigenerational workplace. To attract and retain top talent, employers must offer benefits that are both customizable and inclusive. This means providing a strong foundation of core benefits — such as healthcare, retirement plans, and paid time off — while also offering supplemental options like mental health resources, career development programs, and flexible work arrangements that employees can tailor to their unique needs and life stages.

2. Understanding and Engagement Drive Success: Building an effective benefits strategy starts with gaining deep insight into employee demographics and preferences across generations. Employers should use surveys, focus groups, and workforce data to uncover both generational differences and shared priorities. Just as important is actively engaging employees through multi-channel communication — such as webinars, digital guides, and one-on-one sessions — to ensure they understand and utilize the full range of available benefits.

3. Adaptability Is Key to Long-Term Relevance: Employee needs and expectations are constantly evolving due to shifts in healthcare, the economy, and technology. To keep benefits plans relevant and competitive, employers must regularly assess and update their offerings. By staying agile and responsive to changes, organizations can continue to meet the diverse needs of their workforce and maintain strong recruitment, retention, and overall employee satisfaction.

DoseSpot study: Many patients are overpaying for GLP-1s

By Paige Minemyer - Concern about the cost of GLP-1s remains high, and a new study suggests it's not uncommon for patients to overpay for these drugs. E-prescribing company DoseSpot released a study Monday that analyzed more than 100,000 prescriptions for GLP-1s and found they likely overpaid by a collective $10.2 million. Most (92%) of prescriptions included at the study could have been obtained at a lower price. Read Full Article…

HVBA Article Summary

1. Potential for Massive Cost Savings: A recent study revealed $10.2 million in potential savings related to GLP-1 prescriptions, which, when extrapolated to the estimated 32 million users nationwide, indicates a multi-billion-dollar savings opportunity. Notably, around $7 million of these savings stemmed from manufacturer-sponsored savings programs, highlighting their significant impact on reducing medication costs.

2. Need for Better Information Sharing: Tools like DoseSpot can play a crucial role in bridging the gap between cost-saving opportunities and patient awareness. By surfacing real-time savings data to providers at the point of care—or even before a visit—these platforms ensure that patients are informed about available financial assistance when being prescribed GLP-1 medications. They can also follow up with patients directly via text messages to reinforce this awareness.

3. Adherence Remains a Major Challenge: The study found that only 46.3% of patients continued taking their GLP-1 medications after 180 days, raising concerns about long-term treatment effectiveness and patient outcomes. Cost remains the primary barrier to adherence, suggesting that broader access to manufacturer savings programs could play a vital role in improving medication compliance and long-term health benefits.

As costs rise, employee benefits strategies are shifting to prioritize value

By Tom Starner - Heightened economic uncertainty combined with increased financial pressures on budgets are transforming how HR and benefits leaders design employee benefit strategies, according to a recent survey. The 2025 WTW Benefit Trends Survey from the global advisory, broking and solutions company found that employers are looking to spend smarter, sharpen focus and utilize benefits while continuing to drive engagement, retention and purpose. Read Full Article… 

HVBA Article Summary

1. Rising Costs Drive Strategic Shifts: A growing majority of employers (90%, up from 67% in 2023) now identify rising costs—particularly in healthcare—as the dominant factor influencing changes to their employee benefits strategies. As a result, cost control has become a central focus, outweighing efforts to enhance or expand benefits. Employers are increasingly challenged to deliver value while managing the financial burden of medical inflation and high-cost services.

2. Value and Personalization Over Expansion: Rather than adding more benefits, most organizations are aiming to maximize the effectiveness of their existing offerings. This includes efforts to improve financing, leverage better-value vendors, and offer more personalized benefits that directly address employee needs. Priorities include supporting mental health, financial wellbeing, and family care, with a shift toward solutions that can be tailored to individual circumstances for greater impact.

3. Enhanced Communication and Targeted Support: To help employees make better use of their benefits, employers are investing in improved communication tools, including behavioral nudges and navigation support. Many are also reevaluating vendor performance, using employee feedback to guide decisions. Consolidating programs, auditing plans, and revisiting contracts are key tactics being used to ensure benefits align with what employees value most, while also improving the overall experience and effectiveness of benefit delivery.