Health & Voluntary Benefits Association® Convenes 18th Annual Board Meeting & National Conference at Ocean Casino Resort in Atlantic City

By HVBA – The Health & Voluntary Benefits Association® (HVBA) today announced the commencement of its 18th Annual Board Meeting and Benefits Roadshow at the Ocean Casino Resort in Atlantic City. The event brings together more than 140 industry professionals, including senior executives, brokers, carriers, thought leaders, and technology innovators from across the United States. Read Full Article...

HVBA Article Summary

1. HVBA’s Premier Industry Event Promotes Strategic Collaboration: The HVBA annual conference stands as the association’s most significant national gathering, bringing together top executives, advisors, and stakeholders in the health and voluntary benefits industry. The event opens with a closed-session board meeting, where more than 750 years of combined leadership experience are leveraged to examine emerging trends, regulatory developments, and long-range strategic initiatives for 2026. This session sets the tone for a forward-thinking, collaborative agenda aimed at shaping the future of the benefits landscape.

2. Innovation Sessions Deliver Forward-Looking Insights and Practical Solutions: The afternoon Innovation Sessions provide a dynamic platform for industry experts to explore a wide range of timely and impactful topics. Presentations address key areas such as workforce financial wellness, artificial intelligence and machine learning in benefits operations, pharmacy cost containment, Medicare navigation, workplace violence insurance, and specialty risk solutions. Featured organizations—including SAVVI Financial, InsightAlly, Solofsky Financial Group, NWVSA, MotivityCare, and Agentic Brain—share actionable strategies and real-world innovations that help stakeholders manage rising healthcare costs, improve employee well-being, and modernize benefit delivery systems. Sponsor spotlights from SGIC, JUICE Financial, and The Standard further enhance the educational and networking experience.

3. Recognition, Community Impact, and Continued Industry Leadership: The event concludes with a celebratory evening that includes a networking reception, the HVBA Hall of Fame & Industry Leadership Awards, and a charity auction benefiting HVBA and Trinity Oaks Outdoors. This portion not only honors outstanding contributions to the industry but also underscores HVBA’s dedication to social impact. The conference as a whole reflects HVBA’s broader mission to support employer groups, brokers, carriers, and vendors through ongoing education, credible research, and widely accessed publications like the Daily Industry Report, which now reaches over 26,000 subscribers.

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GOP doubles down on ACA subsidy alternatives

By Peter Sullivan – Republicans are taking a harder line against extending enhanced Affordable Care Act subsidies — and doubling down on an alternative plan that would send the money directly to consumers. Why it matters: President Trump's opposition to an extension makes it increasingly unlikely that Republicans will agree to renew the tax credits, even though it's not clear how the GOP alternative would work or whether the party can reach a consensus. Read Full Article...

HVBA Article Summary

1. Diverging Republican Approaches to ACA Subsidies: President Trump has rejected the idea of extending Affordable Care Act (ACA) subsidies, instead advocating for a plan that sends money directly to individuals. However, he has not provided specifics on how this would work. In contrast, Senate Republicans like Bill Cassidy are proposing alternative strategies, such as redirecting enhanced subsidies into Health Savings Accounts (HSAs). These accounts would help individuals with high-deductible ACA plans manage out-of-pocket costs and promote consumer-driven healthcare spending, aiming to shift control away from insurance companies.

2. Concerns Over Market Stability and Affordability: Some GOP-backed proposals suggest allowing individuals to purchase lower-cost insurance plans that do not meet ACA standards. Health policy experts caution that such changes could destabilize the insurance marketplace by encouraging healthier people to opt out of ACA-compliant plans, leaving a risk pool skewed toward sicker individuals. This could lead to rising premiums and fewer affordable options for those who need comprehensive coverage. Even without a full market collapse, the absence of enhanced subsidies may leave millions unable to afford insurance.

3. Partisan Gridlock Threatens Bipartisan Solutions: Although some Senate Republicans have expressed openness to negotiating a bipartisan extension of ACA subsidies, significant political hurdles remain. Disagreements over issues such as the application of the Hyde Amendment—which restricts federal funds from being used for abortion—complicate potential compromise. Trump's alternative proposal, while unlikely to pass with the required 60 Senate votes, could still serve as political cover for GOP lawmakers opposed to subsidy extensions. The growing partisan divide makes it increasingly difficult for moderates in both parties to find common ground on healthcare affordability.

Best, worst US states for healthcare cost, quality, access: Gallup

By Kristin Kuchno - The overall U.S. healthcare system received a “C” grade from a broad survey of U.S. adults, according to the West Health-Gallup Center for Healthcare in America, which released its inaugural report, “State of the States 2025: Insights on Healthcare in America.” Nationwide, the healthcare system received a “D+” for cost, a “C+” for quality and a “C+” for access. The rankings are based on an online survey of 19,535 U.S. adults conducted June 9 to Aug. 25 across all 50 states and the District of Columbia. Respondents graded the healthcare system in their state, with letter grades converted to a 4.0 GPA scale for analysis. Read Full Article…

HVBA Article Summary

1. Widespread Cost Concerns and Access Barriers: Nearly half (47%) of Americans express concern about being unable to afford healthcare in the next year, highlighting a broad sense of financial vulnerability. Additionally, 30% of respondents reported skipping recommended medical tests or procedures due to cost, indicating a significant barrier to preventive and ongoing care. A further 25% cited difficulty in finding a provider as a reason for not receiving care, with state-level differences ranging from 14% in Iowa (the top-ranked state) to 36% in New Mexico (ranked 49th), underscoring gaps in health system navigation and accessibility.

2. Significant State-by-State Disparities in Affordability and Quality: The data shows stark differences in healthcare experiences depending on where individuals live. In the 10 lowest-ranked states, 29% of residents were unable to afford prescription medications, compared to just 15% in the top 10 states. Likewise, 40% in the bottom states skipped medical procedures due to cost, versus 25% in the top states. Perceptions of care quality also varied, with 71% of Americans saying their provider ensures they get necessary screenings, ranging from a high of 78% in Massachusetts and Rhode Island to a low of 59% in Oregon and Wyoming — reflecting uneven quality across state lines.

3. Health Systems Responding to Demand and Access Pressures: Healthcare providers across the country are facing increasing pressure from rising patient demand and limitations in system capacity. In response, many hospitals and health systems are investing in expanding their ambulatory (outpatient) networks and implementing telehealth services. These strategies aim to reduce access barriers and improve care delivery, particularly in areas where affordability and access are pressing concerns, as reflected in the varying state performance rankings.

Why Health Plans Are Reclaiming Utilization Management, and What It Takes to Do It Right

By Matt Cunningham – For years, utilization management (UM) was quietly delegated away for scale, speed, and supposed efficiency. But today, health plans are hitting the breaking point. Prior authorizations, a core function of UM, have become synonymous with administrative gridlock. Providers are overwhelmed. Members are frustrated. Regulators, including the Centers for Medicare & Medicaid Services (CMS) through the Final Rule CMS-0057-F, are intervening. Even the industry’s own trade group, AHIP, has acknowledged the problem with a collective pledge to modernize prior authorization.. Read Full Article...

HVBA Article Summary

1. Strategic Shift Toward Insourcing to Regain Control: Health plans are increasingly moving away from fully delegated utilization management (UM) models and adopting modular or hybrid insourcing strategies. This shift stems from the limitations of past delegation—such as clinical opacity, fragmented workflows, and limited adaptability to regulatory changes. By bringing key UM functions back in-house, especially decision-making and infrastructure, plans are reclaiming strategic control while still leveraging vendor expertise where appropriate, marking a significant evolution in care management.

2. Modern Insourcing Centers on Transparency, Automation, and Trust: Today’s insourcing isn’t about reverting to manual processes but about redesigning UM with scalable technology and aligned oversight. Health plans are using transparent clinical logic, AI-powered but explainable automation, and seamless integration into provider workflows to build systems that are both efficient and trustworthy. This approach not only reduces provider abrasion and unnecessary appeals but also ensures compliance with clinical standards and regulatory expectations.

3. Compliance as a Catalyst for Broader Transformation: Forward-thinking health plans are treating regulations like CMS-0057-F not just as compliance checkpoints but as opportunities to modernize and differentiate. They are segmenting UM activities based on complexity and volume, investing in real-time decision infrastructure, and tracking metrics like provider satisfaction, clinical quality, and appeal rates. This proactive mindset transforms mandated change into strategic momentum and aligns UM systems with long-term enterprise goals.

ACA subsidy uncertainty could fuel demand for short-term, supplemental health plans

By Allison Bell – Rising health care costs and uncertainty about federal health insurance premium subsidies could make this a good year for sales of short-term health insurance products and supplemental health insurance products. Jeff Smedsrud gave that assessment last week via email. Smedsrud was the chief executive of IHC Specialty Benefit and the co-founder and original CEO of HealthCare.com. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Alternative Insurance Products Are Gaining Attention: Non-ACA (Affordable Care Act) insurance products—such as short-term health insurance, hospital indemnity, and critical illness plans—are increasingly being promoted as supplemental or standalone options. These products fall outside ACA regulations, allowing for more flexibility in pricing and coverage structures. As the cost of group health insurance continues to rise, especially for employers and workers facing high deductibles, these alternatives may offer some financial relief. They are particularly appealing to individuals and employers seeking more affordable solutions in a volatile insurance market.

2. Flexibility Needed Amid Premium Subsidy Uncertainty: Many people purchasing individual health coverage through ACA exchanges are uncertain whether the expanded COVID-era premium subsidies will be extended or reduced. This uncertainty creates challenges for budgeting and planning, particularly for those who rely on those subsidies to make coverage affordable. As a result, there is a growing interest in using non-ACA plans as a way to remain insured while staying adaptable to changes in federal policy. These alternative plans can serve as a bridge while waiting for legislative clarity regarding the future of healthcare subsidies.

3. Potential Strategy for Interim Coverage: For individuals who do not receive employer support and cannot afford full ACA premiums, combining a low-cost ACA plan with non-ACA products is being suggested as a viable interim solution. This approach allows people to take advantage of grace periods tied to ACA plans—30 days for unsubsidized and 90 days for subsidized enrollees—while still maintaining some level of protection. In the event that Congress reinstates higher subsidies, these individuals might become eligible for special enrollment and re-enter full ACA coverage. This stopgap strategy ensures at least minimal coverage during periods of policy transition and financial strain.

Drug Channels News Roundup, November 2025: PBM Revolution, Cuban’s Stelara Challenge, Express Scripts’ Price Games, U.S. Drug Spending Reality, and the AFP Reckoning

By Adam J. Fein, Ph.D. - Here are some intriguing hints that employers are finally gearing up to reshape their pharmacy benefit manager (PBM) relationships. Read Full Article... 

HVBA Article Summary

1. Employer Dissatisfaction Is Driving Talk of a PBM Overhaul: Employers are increasingly frustrated with the opacity and complexity of traditional pharmacy benefit manager (PBM) arrangements. Survey data referenced in the article indicates that many plan sponsors are preparing to rebid their PBM contracts, evaluate acquisition-cost models, or even switch to emerging PBMs that promise greater clarity and alignment. While these shifts indicate a strong desire for change, the article notes that employers have expressed similar intentions in the past without fully acting on them—suggesting that meaningful reform will depend on whether these stated plans translate into real contract and model changes.

2. A Potentially Significant Biosimilar Pricing Disruption Is Emerging: The article highlights the unusually low-priced launch of a Stelara biosimilar through Mark Cuban’s cost-plus model, which offers the product at a fraction of the standard list price. This development challenges entrenched PBM-linked pricing structures, where rebate-driven strategies often favor high-list-price, high-rebate products over low-cost alternatives. By undercutting the market to such an extreme degree, the new biosimilar could pressure both payers and PBMs to rethink formulary placement and cost-sharing strategies—though the article cautions that widespread adoption will depend on whether employers genuinely move away from rebate-centric approaches.

3. U.S. Drug Spending Appears More Moderate Globally, But System-Wide Costs Remain High: Using recent international data, the article emphasizes that U.S. net drug spending, as a share of overall healthcare expenditures, is not an outlier compared with other major countries—it falls in a mid-range band. This contrasts with the popular narrative that U.S. drug costs alone are disproportionately responsible for national healthcare spending challenges. Instead, the article points out that virtually all components of the U.S. health system are priced higher than those abroad. As a result, focusing narrowly on brand-name drug prices risks overlooking the broader structural drivers contributing to the nation’s high healthcare costs.

Telehealth gets a short extension, and faces a looming deadline

By Ron Southwick– Telehealth programs are resuming normal operations with the reopening of the government, but there’s not much time for providers to savor the moment. When Congress and President Trump signed off on legislation restoring the government, the bill included short-term extensions for telehealth and hospital-at-home programs. The legislation also allows retroactive payment for telehealth services when the waivers lapsed. Read Full Article...

HVBA Article Summary

1. Short-Term Restoration of Telehealth Waivers: The recent government shutdown led to a lapse in Medicare waivers for telehealth and hospital-at-home programs, causing major disruptions in care for over a month. Many Medicare patients lost access to virtual care, and hospitals were forced to transfer home-based acute care patients back to in-patient settings. Although the new short-term spending bill restores these waivers retroactively, they are only reinstated through January 30, 2025, leaving the future of such programs uncertain yet again.

2. Urgent Need for Long-Term Policy Stability: Kyle Zebley, a policy leader with the American Telemedicine Association, acknowledged the temporary win but emphasized the need for durable legislative solutions. He warned that short-term fixes do not provide the necessary predictability for healthcare providers to confidently invest in or scale telehealth and hospital-at-home services. Zebley advocates for either permanent legislation or at least a multi-year extension to ensure continuity and planning stability across the healthcare system.

3. Broad Bipartisan Support, but Repeated Short-Term Fixes: While both Republican and Democratic lawmakers, along with Presidents Trump and Biden, have shown strong support for telehealth since the COVID-19 pandemic, Congress has failed to enact a long-term policy. This is the third temporary extension in under a year, causing ongoing instability. According to the American Hospital Association, many health systems are delaying the launch of hospital-at-home programs due to the unpredictable nature of federal backing, despite the proven success and growing interest in such care models.