"Window shopping" becomes a pain point in ACA drama

By Peter Sullivan – Premium increases are starting to hit home for millions of Americans as state-run Affordable Care Act marketplaces begin posting rates for next year that are based on the assumption Congress won't renew expiring financial assistance. Why it matters: Sticker shock could lead many Americans to conclude health coverage is out of reach while the government remains in a shutdown that centers on the fate of enhanced ACA subsidies that will sunset at year's end. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. ACA Premium "Window Shopping" Has Begun in Select States: A preview period known as "window shopping" for 2026 Affordable Care Act (ACA) premiums is now underway in several states, including California, Kentucky, and Vermont. This allows enrollees to review upcoming insurance plan costs before formal enrollment begins—October 15 in Idaho and November 1 nationwide. Early data reveals that premiums could significantly increase without continued federal subsidies, affecting millions of Americans.

2. Debate Over Subsidy Extensions Highlights Political Divide: Democrats are seizing on projected premium increases to advocate for an extension of enhanced ACA subsidies, citing examples of individuals facing drastic monthly hikes. Meanwhile, Republicans have expressed willingness to negotiate subsidy extensions but insist on separating those talks from government funding measures. They also emphasize the need for reforms, such as introducing income caps and ending $0 premium plans, which they claim may encourage fraud.

3. Rising Premiums Could Increase Pressure on Lawmakers: As early premium estimates become public and open enrollment nears, political pressure is mounting on both parties. The potential for substantial premium hikes, especially in red states with high enrollment like Florida and Texas, has prompted some Republicans in tight races to support short-term subsidy extensions. Public awareness of rising costs could influence bipartisan negotiations and shape the healthcare policy debate heading into the 2024 election cycle.

IRS publishes 2026 benefits parameters for cafeteria plans, health reimbursement plans

By Allison Bell – Fortunetellers already know how U.S. benefits professionals will spend some of their time from now through mid-2027: They will keep searching the internet for the minimum numbers, maximum numbers and other numbers that shape how the tax breaks for health benefits and other benefits work in 2026. The Internal Revenue Service publishes several batches of inflation-adjusted benefits program "parameters" throughout the year. One of the longest usually comes out in October, and, in spite of the effects of the federal government shutdown, the IRS managed to post the October parameters update last week. The new "revenue procedure" provides parameters for benefits arrangements such as cafeteria plans and qualified small employer health reimbursements, but not, for example, for health savings accounts or high-deductible health plans. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Annual Inflation Adjustments by IRS: The IRS annually updates various benefits parameters to reflect inflation, which affects tax breaks related to health and other employee benefits. The 2026 adjustments show an average increase of 2.55%, with some parameters increasing by as much as 4.62%. These updates are essential for benefits professionals to understand the limits and thresholds applicable for the upcoming year.

2. Scope of Updated Parameters: The recent revenue procedure includes updated figures for cafeteria plans and qualified small employer health reimbursement arrangements (QSEHRAs), but excludes parameters for health savings accounts (HSAs) and high-deductible health plans (HDHPs). This distinction highlights the specific focus of the IRS updates and the need for employers and benefits administrators to track multiple sets of parameters depending on the benefits offered.

3. Specific Parameter Changes: Key changes include increases in the employee health insurance expense threshold for small employers to $34,100, the cafeteria plan health flexible spending arrangement limit to $3,400, and the maximum unused value carryover to $680. Additionally, QSEHRA maximum reimbursements for individuals and families rose to $6,450 and $13,100 respectively. These changes impact how employers structure benefits and how employees can utilize tax-advantaged accounts.

A new wave of middlemen offers 'alternative funding' for specialty drugs. Patients bear the risks

By Anastassia Gliadkovskaya – As someone living with cardiac sarcoidosis, 60-year-old Kevin Danahy can’t afford to have bad health insurance. To control the inflammation in his heart, he needs an infusion of Remicade every other month, which he gets at Beth Israel in Boston. The infusion costs thousands of dollars out of pocket, so Danahy typically opts for costly PPO plans for reliable coverage. This past spring, when his wife got a job at nursing home operator Stellar Health Group, Danahy joined her health plan. Like always, he reached out to his doctor to start the process of getting insurance approval for his infusions. Read Full Article...

HVBA Article Summary

1. Emergence and Role of Alternative Funding Programs (AFPs): AFPs are third-party vendors that claim to help self-insured employers reduce specialty drug costs by obtaining medications through alternative sources such as pharmaceutical patient assistance programs, charities, or international sourcing. These programs often encourage employers to exclude specialty drugs from coverage or help patients access copay assistance. While AFPs promise cost savings, they operate in a legally and ethically gray area and can contribute to treatment delays and patient confusion.

2. Patient Risks and Treatment Delays: Patients relying on AFPs often face significant delays in receiving medications, with an average wait time of 68 days reported in a 2024 survey. These delays can worsen health conditions and lead to increased emergency room visits or additional prescriptions. The complexity and opacity of AFP operations can leave patients responsible for large medical bills, as in the case of Kevin Danahy, who faced unexpected charges and treatment interruptions due to AFP involvement.

3. Regulatory and Ethical Concerns: AFPs raise concerns among pharmaceutical companies, patient advocates, and regulators due to their impact on patient assistance programs and potential misuse of resources intended for vulnerable patients. Some pharmaceutical companies have prohibited AFP involvement in their assistance programs, and legal actions have been taken against AFPs like Payer Matrix. Regulatory bodies such as the FDA and FTC have yet to take decisive enforcement actions, while states like Louisiana are beginning to investigate AFPs. The lack of clear regulation leaves patients and employers navigating a complex and risky landscape.

Why million-dollar benefits go to waste

By Laura Cave – Companies are investing millions into comprehensive benefits packages, but many are still frustrated by low participation and engagement from their employees. A significant gap exists: 39% of employees aren't using their benefits due to a combination of uncertainty, inertia and confusion about how to sign up or leverage them, which Betterment at Work found in a recent survey. This isn't a personal failure on the part of those employees; instead, it represents a fundamental failure in how these benefits are designed. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Complex Benefits Systems Hinder Employee Engagement: Many employees are not taking full advantage of their benefits, with 32% citing affordability concerns and 18% admitting they are unsure what their employer even offers. This confusion is often caused by overly complex materials, such as 47-page PDF guides and one-hour enrollment presentations covering dozens of options, all within a narrow two-week decision window. For today’s overwhelmed workforce, this kind of cognitive overload makes it difficult to navigate and utilize benefits effectively.

2. User-Centered Design Improves Participation: Design-led strategies that prioritize ease of use—such as smart automation, simplified communication, and proactive outreach—can make participation in benefits more natural and less mentally taxing. For instance, tools like AI chatbots and automated reminders can personalize and streamline the experience. Given that 64% of employees still want more proactive communication and education, redesigning the benefits journey to be more intuitive can significantly increase engagement and empower employees to make better financial and health decisions.

3. Measuring Success is Critical for Long-Term Impact: To validate these improvements, companies should track metrics like enrollment and utilization rates, time-to-value(how quickly employees use benefits after becoming eligible), and targeted employee feedback on the user experience. These measurements help demonstrate ROI and guide ongoing enhancements. Ultimately, organizations that reduce friction and make benefits participation effortless will not only improve employee financial wellness over time but also strengthen their competitive edge in attracting and retaining top talent.

As Insurers Drop GLP-1 Coverage, Advocates Search for a Hero in Obesity

By Marissa Plescia – With roughly two in five U.S. adults affected by obesity, GLP-1 drugs have emerged as a promising solution — but their steep price remains a significant hurdle. For instance, GLP-1 drugs have a list price ranging from $936 to $1,349 before insurance coverage, rebates or other discounts are applied. Given the expense, several insurers have decided to stop covering GLP-1s for weight loss, leading to outrage among physicians and advocates, though they are still covering the drug for patients who have diabetes. This has prompted at least one interviewed for this story to say comprehensive coverage in terms of an executive order from the White House may be what is necessary to make sure this drug is available to those who need it. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Costs and Coverage Rollbacks: GLP-1 drugs, which are effective for obesity treatment, have high list prices ranging from $936 to $1,349, leading many insurers such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care to stop covering them for weight loss in many cases. This rollback is also seen in some state Medicaid programs and Medicare does not cover these drugs for weight loss. Employers and insurers are implementing cost-cutting strategies, but coverage remains inconsistent and limited.

2. Advocates and Physicians Express Concern: Medical professionals and advocates argue that discontinuing coverage for GLP-1s is harmful and may be considered malpractice given the drugs' effectiveness in treating obesity, a chronic disease linked to many other health conditions. They emphasize that obesity treatments should be covered like other chronic diseases and that lack of coverage reinforces stigma and worsens health outcomes, especially for vulnerable populations such as women living with obesity.

3. Calls for Policy Change and Broader Access: Experts suggest that an executive order from the White House is needed to make obesity treatment a standard benefit, as relying on Medicare or Medicaid expansions alone would take years to impact coverage broadly. Meanwhile, manufacturers criticize insurers for limiting access, though drug pricing remains a contentious issue. Stakeholders urge insurers to prioritize clinical evidence and patient access to these medications to improve public health outcomes.

California governor signs bill that cracks down on PBMs

By Paige Minemyer – California Gov. Gavin Newsom signed into law legislation aimed at "reining in" pharmacy benefit managers, becoming the latest state to implement regulations on the industry. The bill, signed Friday, would require all PBMs in the state to be licensed by its Department of Insurance and prohibits multiple business practices that have drawn the ire of PBM critics, namely spread pricing arrangements and efforts to steer patients toward affiliated pharmacies. The legislation also mandates that PBMs pass all rebates through to the payer or patient and bars these companies from making exclusivity deals with drugmakers, according to an announcement from Newsom's office. Under the law, PBMs would not be allowed to make "any untrue, deceptive, or misleading statements" and would be limited in how they charge certain fees. Read Full Article...

HVBA Article Summary

1. New Licensing and Business Practice Restrictions: The new California law requires all pharmacy benefit managers (PBMs) to be licensed by the state's Department of Insurance. It prohibits spread pricing and steering patients to affiliated pharmacies, practices that have been criticized for contributing to higher drug costs. This regulatory approach aims to increase transparency and fairness in PBM operations within the state.

2. Rebate Transparency and Fee Limitations: The legislation mandates that PBMs must pass all rebates directly to payers or patients, eliminating the practice of retaining rebates that can obscure true drug costs. Additionally, PBMs are barred from making exclusivity deals with drug manufacturers and are restricted in how they charge certain fees. These measures are designed to reduce hidden costs and deceptive practices in the pharmaceutical supply chain.

3. Industry and Political Responses: While California joins 15 other states in banning spread pricing, the Pharmaceutical Care Management Association (PCMA), representing PBMs, criticized the law, claiming it will increase drug costs rather than lower them. The bill reflects growing state-level efforts to regulate PBMs amid stalled federal reforms, highlighting ongoing tensions between regulators, industry groups, and consumer advocates over drug pricing and PBM practices.

80% of Americans fear medical bills could derail their financial goals

By Alan Goforth – Four in five Americans worry that an unexpected medical expense could derail their financial goals, while more than a quarter of this group say that a bill of less $1,000 would cause financial hardship. Younger generations are especially anxious, with nearly 90% of Gen Z and millennials saying an unplanned medical cost would disrupt their financial plans, compared to just 56% of baby boomers. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Financial Preparedness for Medical Emergencies Is Limited: A significant portion of Americans are not financially prepared to handle unexpected medical expenses without potentially jeopardizing long-term security. When faced with a costly, unplanned medical bill, 48% of survey respondents said they would resort to a payment plan, 31% would use general savings, and 28% would rely on credit cards. Notably, 12% indicated they would tap into their retirement accounts through a hardship withdrawal, underlining the link between health crises and financial vulnerability.

2. Digital Platforms and AI Are Influencing Benefits Decision-Making: Younger generations are increasingly turning to non-traditional sources for benefits information. Over two-thirds of Gen Z use social media platforms like TikTok, Instagram, or YouTube to understand their workplace benefits. Millennials lead in adopting AI tools, with 30% using them for benefits guidance. Despite this digital engagement, there's a gap in professional advice: although 80% value having a financial advisor, only 20% consult one during open enrollment.

3. Voluntary Benefits Are Undervalued Yet Highly Effective When Understood: Misunderstanding and complexity hinder the adoption of voluntary benefits, even though they offer strategic advantages. More than 40% of employees lack confidence in understanding these offerings, but over 80% find them valuable once properly informed. Among small-business owners, 75% believe offering such benefits signals care and commitment, yet nearly 40% report low employee participation and over 25% admit to struggling with understanding the solutions themselves. This reflects an opportunity for better education and communication to enhance utilization and retention.

AI vs Doctors? That's the Wrong Question

By Sriman Swarup, MD, MBA – In July, Harvard staged an unusual experiment. A master diagnostician from Massachusetts General Hospital, internist Daniel Restrepo, MD, was pitted against CaBot, an artificial intelligence (AI) model, in a public "diagnosis duel." Both were given the same complex case: a 41-year-old with recurrent fevers, a rash, fainting spells, ankle swelling, and a history of stent placement. Restrepo spent weeks preparing his presentation of the case. CaBot took 6 minutes. Both arrived at the same conclusion: Löfgren syndrome, a presentation of sarcoidosis. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Collaboration Over Competition: The article emphasizes that the debate should not be about AI versus doctors, but rather how AI and physicians can work together. While AI can quickly surface rare diagnoses, the human role in contextualizing, communicating, and guiding patients through complex decisions remains irreplaceable. This partnership can enhance care rather than replace the physician's role.

2. AI as a Tool for Equity and Efficiency: AI has the potential to reduce delays in diagnosis, especially in underserved or rural areas where access to specialists is limited. By providing rapid diagnostic suggestions, AI can help shorten wait times, reduce unnecessary testing, and bring expert-level insights to locations lacking subspecialists, thus promoting more equitable healthcare access.

3. Challenges in Integration and Trust: The real challenge lies in integrating AI into clinical workflows without overwhelming clinicians and maintaining transparency and patient trust. Physicians must lead in designing systems that present AI outputs clearly and allow for contestability, ensuring that AI augments rather than dictates care. Ethical, communication, and design considerations are crucial for successful adoption.