DOL Cybersecurity Guidance and Health and Welfare Plan Gaps

By Steven Mindy - Almost all health plans must comply with the Health Insurance Portability and Accountability Act. However, all employee benefit plans subject to the Employee Retirement Income Security Act, including health plans, other welfare plans (for example, disability or life insurance) and retirement plans, must follow the U.S. Department of Labor’s cybersecurity guidance. Read Full Article…

HVBA Article Summary

1. DOL Cybersecurity Guidance Applies Broadly: In September 2024, the Department of Labor (DOL) confirmed that its April 2021 cybersecurity guidance is not limited to retirement plans but applies to all employee benefit plans, including health and disability plans. The guidance encourages plan sponsors, fiduciaries, and service providers to adopt comprehensive cybersecurity measures such as documented programs, risk assessments, vendor audits, and breach response procedures.

2. Courts Uphold DOL Investigations into Cybersecurity: The 7th Circuit’s decision in Walsh v. Alight Solutions affirmed the DOL’s authority to subpoena cybersecurity information from plan vendors, even those that are not fiduciaries. The court emphasized that cybersecurity practices are relevant to potential ERISA violations and rejected attempts to limit the scope of DOL investigations, reinforcing the need for all plan-related entities to maintain strong cybersecurity protocols in line with DOL guidance.

3. Cybersecurity Risks Extend Beyond HIPAA and Retirement Plans: Health and welfare plans may have data-sharing arrangements that fall outside HIPAA protections, and disability plans are not subject to HIPAA at all—leaving gaps that the DOL may still scrutinize. Cases involving fraud, such as Disberry v. Colgate-Palmolive, highlight the legal risks for plans and vendors when participants suffer financial losses. Courts are showing a willingness to provide relief, whether under ERISA or through common-law negligence claims, making proactive cybersecurity and insurance coverage essential for all benefit plans.

Bipartisan bill seeks to reform prior authorization

By Ashleigh Fields - Rep. Mark Green (R-Tenn.) reintroduced a bill Thursday seeking to reform prior authorization requirements in Medicare, Medicare Advantage, and Part D prescription drug plans requiring only specialty board certified physicians to make important decisions about treatment. Read Full Article… 

HVBA Article Summary

1. Bipartisan push to reform prior authorization: Rep. Mark Green, backed by several GOP and Democratic lawmakers, introduced the Reducing Medically Unnecessary Delays in Care Act of 2025 to streamline prior authorization processes for Medicare and Medicare Advantage recipients, aiming to eliminate unnecessary red tape and empower doctors to make timely medical decisions.

2. Physician and patient frustrations drive legislative urgency: Green, a cancer survivor and former physician, emphasized how delays caused by prior authorization can be life-threatening. A 2024 AMA survey found 94% of physicians believe these requirements harm patient care, with nearly a quarter reporting they have led to hospitalizations.

3. Legislation would require medically qualified reviewers: The proposed bill mandates that insurance prior authorization decisions be reviewed by physicians experienced in the relevant medical field—addressing concerns that non-medical personnel or AI systems currently make critical healthcare determinations.

House members roll out bipartisan PBM drug price transparency bill

By Allison Bell - Two Republicans and two Democrats joined together Thursday to introduce a bill that could create extensive new reporting requirements for pharmacy benefit managers that serve employer plans. The new Prescription Drug Transparency and Affordability Act bill would apply to PBMs that serve both employers with self-insured plans and employers with fully insured group health coverage. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Bipartisan Effort to Increase Drug Pricing Transparency: A new bill led by Rep. Kristen McDonald Rivet (D-Mich.) and cosponsored by a bipartisan group of lawmakers seeks to bring greater transparency to how pharmacy benefit managers (PBMs) influence drug pricing, amid concerns that large PBMs may be prioritizing profits over savings for payers and patients.

2. Enforcement with Penalties for Noncompliance: Unlike previous proposals such as the Hidden Fees Disclosure Act, the new bill introduces enforcement mechanisms, including penalties of up to $100,000 for failure to report or knowingly submitting false information, applying to both PBMs and related entities such as manufacturers and wholesalers.

3. Detailed Reporting Requirements Without Patient Data: PBMs would be required to submit summary-level reports detailing drug pricing components—such as plan and pharmacy compensation, drug costs, and patient out-of-pocket expenses—while ensuring the protection of personal health information.

States consider crackdowns on AI in prior authorization 

By Rylee Wilson - Several states are considering regulating how insurers can use AI in prior authorization. In January, a California law took effect that prohibits payers from making coverage decisions based solely on artificial intelligence algorithms. The law requires any denial, delay or modification of care to be reviewed by a physician or other qualified healthcare provider. Read Full Article…

HVBA Article Summary

1. States Push Back on AI in Healthcare Decisions: In early 2025, lawmakers in Illinois, Georgia, Texas, Rhode Island, Minnesota, and Florida introduced legislation aimed at restricting the use of AI in prior authorization decisions by health insurers. While the momentum reflects growing concern over automated decision-making in healthcare, none of these bills have passed their respective state legislatures as of March 26.

2. Legal and Regulatory Scrutiny Grows: Insurers’ use of AI in prior authorization is under increasing legal pressure, with lawsuits filed against UnitedHealth Group and Humana alleging that AI tools like naviHealth were wrongfully used to deny postacute care for Medicare Advantage patients. At the same time, federal lawmakers and agencies are stepping in to call for greater oversight and accountability.

3. Balancing AI Potential with Safeguards: In response to the growing use of AI, CMS issued guidance in 2024 permitting algorithms to support coverage decisions as long as they adhere to established federal criteria. Dr. Mehmet Oz, President Trump’s nominee to lead CMS, endorsed the potential of AI to improve efficiency but emphasized reducing the number of procedures requiring prior authorization and using AI to monitor insurers in real time for inappropriate denials.

The Future Of Personalized Healthcare And Concierge Medicine

By Dustin Mangas - In an era where healthcare is becoming increasingly transactional and impersonal, I see concierge medicine emerging as a solution to this broken system. My journey into this space began when I witnessed firsthand how overworked physicians and frustrated patients were stuck in an inefficient system that largely prioritized volume over value. Read Full Article…

HVBA Article Summary

1. Concierge Medicine Empowers Physicians and Patients Alike: Transitioning to a concierge model can reignite a physician’s passion for medicine by fostering deeper, more meaningful relationships with patients. It offers greater professional autonomy, improved work-life balance, and a chance to return to patient-centered care—often serving as a powerful antidote to burnout and administrative overload.

2. The Market is Growing Rapidly with Flexible Models Emerging: The concierge medicine market is experiencing explosive growth both globally and in the U.S., driven by rising demand for direct physician access and personalized care. Flexible pricing structures, including tiered memberships and Direct Primary Care models, are making concierge care more accessible to a broader range of patients, helping to break the stigma of exclusivity.

3. Technology and Personalization are Driving the Future of Care: Concierge practices are leading the way in adopting innovative technologies like AI-powered diagnostics, wearable health trackers, and telemedicine tools. These advancements enable real-time patient monitoring, early intervention, and customized treatment plans—allowing physicians to deliver more proactive, preventive, and efficient care while staying ahead in a rapidly evolving healthcare landscape.

Older Adults Favor Medicare Coverage for Obesity Meds

By Kristen Monaco - In a national poll of older adults, interest in using weight management medications was high, and most thought Medicare should cover these drugs. Among 2,657 National Poll on Healthy Aging respondents ages 50 to 80 years, 35.1% of all respondents expressed interest in using weight management medications, including 59.1% of those with a body mass index (BMI) of 30 or greater, found Lauren Oshman, MD, MPH, of the University of Michigan Medical School in Ann Arbor, and colleagues. Read Full Article…

HVBA Article Summary

1. Strong Public Support for Coverage: A large majority of survey respondents (83.2%) believe health insurance should cover weight management medications, and 75% support Medicare coverage. However, only 30.2% said they would be willing to pay higher premiums for that coverage.

2. Coverage Gaps and Double Standards: Experts highlight a disconnect in Medicare policy, which excludes obesity medications while covering the same drugs for diabetes. This inconsistency limits access for patients with obesity—a chronic condition that often coexists with other serious health issues.

3. Inequities in Access and Interest: People with clinical obesity, chronic health conditions, or lower income were significantly more interested in using weight management medications but may face barriers due to cost. Support for insurance coverage was strongly linked to the belief that obesity is a chronic disease rather than a lifestyle choice.

Provider-led bundle programs can cut health care costs for employers

By Michael Popke - Many employers don’t realize that provider-led bundle programs — which offer comprehensive health care services for costly health conditions at a single, pre-determined price to employers — can cut health care costs significantly. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Provider-led bundles prioritize clinical care and complement existing benefits: Unlike traditional benefit programs or more familiar payer-led bundles, provider-led models like Vanderbilt Health’s MyHealth Bundles are built around clinical care, offering end-to-end services for high-cost conditions at a single, predictable fee without replacing current benefits.

2. Bundled care models show measurable impact on cost and outcomes: Employers using MyHealthBundles reported a 16% reduction in healthcare spending and improved consistency in care. Additional outcomes include a 90% return-to-work rate within 90 days for spine surgery patients and fewer unnecessary orthopedic surgeries.

3. Transparency and understanding are key to successful adoption: For employers to make informed decisions, they need access to clear data on cost savings, patient outcomes, and workforce impact. Partnering with trusted providers ensures proper integration and maximizes the value of bundled care programs.