CMS pulls back limits on non-standard ACA plans in final rule

By Paige Minemyer – The Trump administration has finalized annual regulations governing the Affordable Care Act's exchanges, including a plan that would pull back limits on non-standardized plan options offered by insurers. The final Notice of Benefit Payment Parameters was issued late Friday, and the Centers for Medicare & Medicaid Services said in a press release that the rule aims to crack down on fraud — a focus across wide swaths of the government — and afford states greater control over their marketplaces. Under the Biden administration, plans were required to offer certain standardized options and a limited number of alternative plans, with the goal of making the shopping experience easier for consumers. Read Full Article...

HVBA Article Summary

1. Increased Flexibility for Insurers: The new CMS rule removes previous restrictions on the number of non-standardized plans insurers can offer on ACA exchanges. Insurers now have the option to discontinue standardized plans or continue offering them, potentially with changes to cost-sharing structures. This shift is intended to give insurers more flexibility in designing and marketing their coverage options.

2. Expanded Catastrophic Coverage and Cost-Sharing Updates: The rule allows insurers to offer catastrophic health plans for up to 10 consecutive years and broadens the hardship exemption, making these plans more accessible to consumers. Additionally, CMS is updating cost-sharing parameters for both bronze tier and catastrophic plans, with changes for bronze plans effective in 2027 and for catastrophic plans in 2028. These updates aim to provide payers with greater flexibility and potentially more affordable options for consumers.

3. Enhanced Fraud Prevention and State Control: The final rule revives pre-enrollment verifications for certain special enrollment periods to better confirm eligibility for premium tax credits, addressing concerns about improper enrollments. States are also granted more authority to tailor certification reviews and must cover costs for benefits that exceed ACA essential health benefits. CMS is lowering user fees on exchanges, which could help reduce premiums, and removing the transition period for states moving to state-based exchanges.

Five Ways to Start Fixing America’s Health Care System

By Ron Howrigon – I saw an interview with a bomb disposal technician. He made the comment; “Identifying a bomb is easy, disarming it is the hard part.” It made me think about the debate around our current health care problems. It’s easy to point to all the things that are wrong or to throw stones at big insurance companies or Big Pharma. Even though the finger pointing may be warranted, the harder part is coming up with a solution to this ticking time bomb. Read Full Article...

HVBA Article Summary

1. Addressing Vertical Integration and Market Concentration: The article argues that the consolidation of health care companies, particularly through vertical integration, has contributed to rising costs and reduced competition. Breaking up large, vertically integrated health care entities is proposed as a way to restore competition and focus insurance companies on their core business. The author suggests that enforcing existing monopoly rules and using tools like the Herfindahl-Hirschman Index could help identify and address excessive market concentration in the health insurance industry.

2. Reforming Insurance Company Practices and Coverage Policies: The author recommends that insurance company medical directors should be held to the same legal and professional standards as treating physicians when making decisions about patient care. This would increase accountability and potentially reduce delays and denials of care. Additionally, the article calls for universal, evidence-based clinical coverage policies to ensure that treatment decisions are based on patient needs and best practices, rather than varying by insurer.

3. Expanding Access and Moving Toward Universal Coverage: One of the central proposals is to ensure that all Americans have access to health insurance, regardless of employment status or income. The author suggests community rating of premiums, state-level rate approval, and subsidies or tax incentives for small businesses and individuals who cannot afford coverage. The article emphasizes that, given the size of the U.S. economy, financing universal coverage is feasible and should be a national priority.

Republican brings back bill that could cap employers' health benefits tax exclusion

By Allison Bell – A House Republican has brought back a long health care package that could make sweeping changes to employer-sponsored health benefits plans. The package, the Fair Care Act of 2026 bill, could cap the employer health benefits tax exclusion at $10,200 for self-only coverage and $27,500 for family coverage, with the caps adjusted for inflation. Another provision could make contributing to an employee's health savings account the only way for a corporation formed after Dec. 31, 2026, to use the federal health benefits tax exclusion. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Fair Care Act Reintroduced With Consumer-Driven Health Focus: Rep. Bruce Westerman introduced the latest version of the Fair Care Act, describing it as an effort to create a more accessible and functional health care system. The bill emphasizes free-market approaches that encourage individuals to use personal health accounts and direct spending for medical care rather than relying primarily on insurers, employer-sponsored plans, or government programs. The proposal is currently under the jurisdiction of nine House committees and does not yet have any co-sponsors.

2. Latest Version Builds on Prior Unsuccessful Attempts: The newly introduced Fair Care Act is the fifth version of the legislation that Westerman has proposed, with previous versions failing to advance out of committee. The updated bill may receive additional attention because it includes provisions designed to appeal to Republicans who support consumer-directed health care models. The legislation contains more than 75 proposals addressing areas such as Medicare, Medicaid, and individual health insurance coverage.

3. Bill Includes Changes to Employer Coverage and ICHRA Rules: One provision in the bill could eliminate current federal requirements that large employers provide affordable major medical coverage meeting minimum standards or face financial penalties. Another proposal would formally establish federal law governing Individual Coverage Health Reimbursement Arrangement (ICHRA) plans, which currently operate under federal regulations rather than statute. ICHRA plans allow employers to provide workers with funds that can be used to purchase individual or family health insurance coverage.

Employers, Employees Both Play Roles in Managing AI

By Emily Boyle – Leveraging artificial intelligence—and protecting against its dangers—should be a responsibility shared by employers and employees, according to new research from the Transamerica Institute and Mercer Marsh Benefits. The Transamerica Institute, in its “ Employers, Workers, and the New World of Work” report, found that 82% of employers are currently using or planning to use artificial intelligence to “augment their human workforce,” including 97% of large companies (with at least 500 employees), 95% of medium companies (between 100 and 499 employees), and 79% of small companies (fewer than 100 employees). Read Full Article...

HVBA Article Summary

1. Shared Responsibility for AI Integration: Both employers and employees are expected to play active roles in leveraging artificial intelligence within the workplace. Research suggests that successful AI adoption requires not only technological investment but also a workforce that is prepared and willing to integrate AI into daily operations. This shared approach is necessary to maximize AI’s benefits and mitigate its risks.

2. Training and Upskilling Are Critical: Reports highlight that a significant barrier to effective AI implementation is the lack of adequate employee training and digital literacy. Concerns include insufficient knowledge of AI risks, limited capacity for technology teams to support adoption, and employee resistance due to fears of job loss. Addressing these gaps through ongoing reskilling and clear communication can help organizations better harness AI while protecting against potential threats.

3. Cybersecurity Risks Demand Proactive Measures: As AI tools become more sophisticated, organizations face increased exposure to cyber threats such as phishing, social engineering, and deepfakes. Surveys indicate that inadequate cyber threat literacy is a top risk, with over 70% of organizations experiencing at least one major third-party cybersecurity incident in the past year. Employers are encouraged to prioritize digital literacy, involve employees in AI strategy, and treat workforce behavior and training as essential components of their cybersecurity defenses.

Docs remain skeptical of insurers' pledge to ease prior auth: AMA survey

By Paige Minemyer – As payers tout progress made under a pledge to ease burdens around prior authorizations, physicians remain skeptical, a new survey shows. The American Medical Association released the results from a poll conducted in December 2025 of 1,000 physicians on their experiences with prior authorization. Only a third (33%) of those surveyed said they believe that the payers' pledge last summer would lead to significant change. One of the key sources of that skepticism, per the survey, is physicians' first-hand interactions with health plans' representatives. Read Full Article...

HVBA Article Summary

1. Persistent Physician Skepticism: Despite insurers' public pledges to reduce the burden of prior authorizations, most physicians remain doubtful about meaningful change. The skepticism is fueled by ongoing negative experiences with insurer representatives and a lack of visible improvements in the process. This distrust is compounded by years of unfulfilled promises from payers, making it difficult for physicians to believe that recent initiatives will have a significant impact.

2. Administrative Burden and Burnout: The survey highlights that physicians continue to face a heavy administrative workload related to prior authorization requests, averaging 40 submissions per week. High denial rates and increasing complexity contribute to physician frustration and burnout, with the vast majority reporting that these tasks negatively affect their well-being. The lack of clarity around requirements and the unreliability of electronic health record systems further exacerbate these challenges.

3. Limited Technological Progress: While insurers have pledged to promote electronic prior authorization and standardize processes, many physicians report that current technology falls short. Most still rely on phone calls for submissions, and a significant portion find that electronic platforms rarely provide accurate or helpful information about authorization requirements. The slow adoption of effective digital solutions undermines efforts to streamline the process and rebuild trust between providers and payers.

GLP-1s: Rewriting the relationship between pharmacy benefits and stop-loss

By John Thornton – Pharmacy benefits and stop-loss strategy have always been related. But most self-funded employers and their advisors treat them as separate planning exercises with separate teams and timelines. GLP-1 medications are the drug class that’s forcing those conversations together. Injectable GLP-1s can cost more than $10,000 per member per year, and adoption is surging. In a KFF survey last fall, 12% of American adults reported taking GLP-1s. Read Full Article...

HVBA Article Summary

1. GLP-1s Are Changing Cost Dynamics: The rapid adoption and high cost of GLP-1 medications are creating new financial pressures for employer-sponsored health plans. Unlike other high-cost therapies that generate large, episodic claims, GLP-1s are maintenance drugs that require ongoing use, leading to sustained aggregate costs. This shift challenges traditional stop-loss underwriting models, which were not designed to handle such persistent, widespread expense from a single drug class.

2. Adherence and Utilization Add Complexity: Many patients discontinue GLP-1 therapy before achieving meaningful results, making it difficult for employers to predict long-term spending. High discontinuation rates mean that pharmacy claims data at any given time may not accurately reflect annual utilization or outcomes. This unpredictability complicates both budgeting for pharmacy benefits and setting appropriate stop-loss thresholds.

3. Strategic Integration Is Essential: Employers often make pharmacy benefit decisions separately from stop-loss planning, but GLP-1s demonstrate the need for a more integrated approach. Changes in GLP-1 coverage can directly impact stop-loss attachment points, renewal pricing, and claims volatility. Advisors who incorporate real-time pharmacy utilization data into stop-loss discussions are better positioned to manage risk and avoid unexpected financial exposure.

Telemedicine use has not led to increased visits or costs, study finds

By Alan Goforth – The use of telemedicine has not resulted in significantly increased visits and medical spending across various payer types, according to new research led by UCLA and reported in JAMA Network Open. At the onset of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services introduced payment parity with in-person visits, waived geographic restrictions and eliminated out-of-pocket cost sharing, among other policy changes. Lawmakers are debating whether to permanently extend or modify these policies when they expire next year. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Telemedicine Did Not Drive Up Utilization or Costs: The UCLA-led study found that the expansion of telemedicine during the COVID-19 pandemic did not lead to a significant increase in the number of medical visits or overall healthcare spending. This finding addresses concerns that easier access to telemedicine might result in unnecessary or duplicate care. Instead, telemedicine appears to have served as a substitute for in-person visits rather than an additional layer of healthcare utilization.

2. Impact Varied Across Populations but Was Not Statistically Significant: The research examined spending and visit patterns among different insurance types and demographic groups, including urban and rural populations, Medicaid and Medicare recipients, and those with varying levels of social vulnerability. While there were slight increases or decreases in spending among these groups, none of the changes reached statistical significance. This suggests that telemedicine's effects on healthcare costs and access have been relatively uniform across diverse populations so far.

3. Ongoing Policy and Research Considerations: The study's authors emphasize that their analysis only extends through late 2023, a period when telemedicine use was still stabilizing post-pandemic. They caution that more research is needed to evaluate the long-term effects of telemedicine on care quality, health outcomes, and spending. Policymakers are encouraged to continue monitoring telemedicine trends as regulations and payment policies evolve in the coming years.

As GLP-1 Uptake Rises, Metabolic Surgery Rates Decline

By Shrabasti Bhattacharya – Between 2022 and 2024, prescriptions for GLP-1 receptor agonists increased by about 140%, whereas the use of metabolic bariatric surgery decreased by about 34%, indicating a rapid shift from surgical to pharmacologic management of obesity. The impact of increasing GLP-1 medication use on bariatric surgery rates remains unclear. As many payors are requiring prior authorization for GLP-1 receptor agonists, tracking metabolic bariatric surgery volumes is essential to ensure access to appropriate medical and surgical care for patients with obesity. Read Full Article...

HVBA Article Summary

1. Shift Toward Pharmacologic Obesity Management: The study found a significant increase in GLP-1 receptor agonist prescriptions alongside a notable decline in metabolic bariatric surgery rates. This trend suggests that more patients and providers are opting for medication-based approaches to obesity treatment rather than surgical interventions. The shift may reflect growing confidence in the effectiveness and accessibility of GLP-1 therapies.

2. Patient Complexity and Treatment Selection: Patients who underwent metabolic bariatric surgery were generally more medically complex compared to those who received GLP-1 prescriptions or no treatment. This indicates that surgery may be reserved for individuals with more severe or complicated health profiles. The distinction in patient characteristics highlights the importance of personalized treatment decisions in obesity care.

3. Ongoing Need for Comprehensive Obesity Treatment: Despite the rise in GLP-1 use, the study authors emphasize that obesity remains undertreated, with only a small proportion of eligible patients receiving either pharmacologic or surgical interventions. The continued decline in surgery rates raises questions about long-term outcomes and access to multidisciplinary care. Monitoring these trends is important to ensure that patients have access to both optimal medication and surgical options for obesity management.