Average ACA premiums set for 30% spike: Washington Post

By Paige Minemyer – Open enrollment for the Affordable Care Act's (ACA's) marketplaces is just one week away, and premiums are set for a massive spike, federal documents show. Reporters at The Washington Post reviewed data from the Centers for Medicare & Medicaid Services (CMS), and final rate approvals show an average premium increase of 30% for next year. This figure is far and away the highest increase in the past several years. "Window shopping" for plans available on HealthCare.gov opens [today], with the enrollment period beginning Nov. 1. Read Full Article...

HVBA Article Summary

1. Significant Premium Increase for ACA Plans: The upcoming year will see a substantial rise in ACA marketplace premiums, with an average increase of 30% according to federal data. This marks the largest jump in premiums in recent years, which could impact affordability for many enrollees. The increase is expected to be felt immediately as open enrollment begins and consumers start comparing plan options.

2. Political Disagreements Over Subsidies: The spike in premiums comes amid ongoing political debate regarding the future of enhanced premium tax credits. Democrats are advocating for an extension of these subsidies, which were initially introduced during the COVID-19 pandemic and have contributed to high enrollment numbers. In contrast, Republicans prefer to address the subsidies and other policy issues after resolving the government shutdown, highlighting a partisan divide on how to manage ACA affordability.

3. Insurer Proposals Reflect Rising Costs and Utilization: Insurers have justified their proposed premium increases by citing higher utilization and acuity among ACA enrollees. Analysts at KFF noted that median premium requests for 2026 are also elevated, suggesting a trend of rising costs in the individual market. These factors, combined with uncertainty about the continuation of subsidies, are contributing to the significant rate hikes approved for the coming year.

Health Plan Fiduciary How-To: Isn’t the Fiduciary My Broker, TPA or Carrier?

By PLANSPONSOR Staff - Q: Isn’t the fiduciary my broker, TPA or carrier?A: Usually not, unless they have explicitly accepted fiduciary status in writing. Most contracts with service providers (brokers, third-part administrators and pharmacy benefit managers) disclaim discretionary authority, limiting the service provider’s role to ministerial tasks spelled out in the agreement. In a fully insured plan, the carrier is always a fiduciary with respect to claims and appeals administration. That differs, however, from being the named fiduciary, which is almost always the plan sponsor or an individual employee, committee or board of the employer. Read Full Article...

HVBA Article Summary

1. Fiduciary Status Depends on Conduct, Not Title: Under ERISA, fiduciary status is determined by the actions and discretion exercised in plan management or administration, not by job title or contract language. Even if a service provider is labeled as a fiduciary in some respects, the ultimate responsibility often remains with the plan sponsor or named fiduciary. This means employers and designated individuals must be vigilant in understanding their ongoing obligations.

2. Service Provider Oversight Is a Fiduciary Duty: Hiring and monitoring service providers is itself a fiduciary act. Plan sponsors or named fiduciaries must ensure that service providers are performing their contracted duties prudently, charging reasonable fees, and not collecting unauthorized compensation. Ongoing oversight and documentation are essential to demonstrate compliance with fiduciary responsibilities.

3. Recent Legislation Increases Transparency Requirements: The Consolidated Appropriations Act of 2021 amended ERISA to require greater transparency from health plan service providers. Service providers must now disclose all direct and indirect compensation before contracts are entered, renewed, or extended. Additionally, new rules prohibit contracts with “gag clauses” that restrict access to or sharing of cost and quality information, further empowering plan sponsors to fulfill their fiduciary duties.

Anthem to impose 10% penalty on hospitals using out-of-network providers

By Allison Bell – Anthem Blue Cross and Blue Shield — a unit of Elevance Health — will use a new 10% administrative penalty to discourage in-network hospitals and other in-network facilities from using out-of-network providers to care for patients. Anthem's commercial plans may deduct the penalty from their allowed amounts for claims that involve the use of out-of-network providers, and it may cut facilities that use out-of-network providers out of its provider networks. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Anthem's New Policy Targets Out-of-Network Billing: Anthem Blue Cross and Blue Shield is introducing a 10% penalty for in-network hospitals and facilities that use out-of-network providers for patient care. This penalty will be deducted from the allowed claim amounts, potentially impacting the financial arrangements of hospitals that do not comply. The policy is designed to encourage hospitals to use in-network providers and reduce instances of unexpected out-of-network charges for patients.

2. Exemptions and Geographic Scope: The penalty will not apply to emergency care or to cases where out-of-network care has been pre-approved by Anthem. The initial rollout covers in-network facilities in several states, including Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin. Notably, some states in Anthem's market area, such as New York, are not mentioned in the notice regarding the new policy.

3. Broader Context of Surprise Billing and Regulation: The move comes amid ongoing concerns about surprise medical bills, where patients receive unexpected charges from out-of-network providers despite visiting in-network facilities. While the federal No Surprises Act aims to address these issues, disputes over reimbursement rates and the negotiation process continue between insurers and providers. Stakeholders, including employer groups and provider associations, remain divided on whether such out-of-network billing is driven by low insurer reimbursement rates or by provider billing practices.

From Executive Perk to Employee Retention Strategy: Why Concierge Medicine and/or Direct Primary Care Is Now a Business Essential

By Dana Y. Lujan – If you had told me five years ago that concierge medicine would go mainstream, I probably would’ve laughed. The perception was pretty fixed: it was a perk for senior leadership, a flashy benefit for executives, maybe a recruiting chip for top talent. But something’s shifted. With staffing shortages, historic burnout, and rising costs, I’ve watched concierge medicine — and direct primary care (DPC) — move from the margins into the middle of the retention conversation. Employers aren’t looking at it as a luxury anymore. They’re treating it as survival. Read Full Article...

HVBA Article Summary

1. Concierge Medicine and DPC Are Becoming Mainstream Retention Tools: Once seen as exclusive perks for executives, concierge medicine and direct primary care (DPC) are now being adopted by employers as essential strategies to address workforce burnout and retention. The shift is driven by the need to combat staffing shortages and rising healthcare costs, making these models more of a necessity than a luxury. Employers are recognizing that improved healthcare access can directly impact employee satisfaction and retention.

2. Small and Mid-Sized Businesses Are Leading Adoption: Contrary to the belief that large corporations are the primary adopters, smaller companies are often the first to implement concierge and DPC programs. These businesses feel the effects of turnover more acutely, as losing even one employee can have a significant impact on operations and morale. For them, investing in accessible healthcare options is a practical solution to reduce turnover and maintain team stability.

3. Demonstrable Value Is Key to Employer Buy-In: Employers are increasingly demanding measurable outcomes from concierge and DPC programs, such as reduced absenteeism, higher utilization rates, and improved employee satisfaction. Providers must present concrete data to demonstrate the return on investment and effectiveness of these healthcare models. This evidence-based approach is helping to shift the perception of concierge medicine from a status symbol to a fundamental component of employee support and retention strategies.

Surprise medical bills are symptoms of a broken system

By Andréa Caballero – When a primary care provider suspected Audre's son Mason had autism spectrum disorder, the only specialist in their hometown was out-of-network. When Sasha decided to enter a rehab facility for a substance use disorder, the nearest inpatient facility within 100 miles was out-of-network. When Cam needed physical therapy after breaking his leg, he was unable to find a nearby in-network facility. All three had employer-sponsored health insurance with out-of-network coverage, but, as employees of self-insured companies, they were at risk of receiving steep, inflated bills. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Complexity and Lack of Transparency: The article highlights that out-of-network billing is driven by a complicated system involving third-party administrators (TPAs), repricers, and opaque pricing structures. Employers often struggle to understand where their health care dollars are going due to convoluted contracts and hidden fees. This lack of transparency makes it difficult for plan sponsors to assess the true value and fairness of the services provided.

2. Financial and Legal Risks for Employers: Self-funded employers face significant financial exposure from out-of-network claims, which can constitute a notable portion of their total health care spending. Additionally, there is a growing legal risk, as illustrated by lawsuits alleging that plan sponsors failed to fulfill their fiduciary duties under ERISA by not providing adequate information or fair reimbursement practices. These risks underscore the importance of employers being proactive in understanding and managing their health plan arrangements.

3. Recommendations for Greater Accountability: The article suggests that increased transparency is key to addressing the root causes of surprise medical bills. Employers are encouraged to demand clear, itemized disclosures of all fees and claims from TPAs, require annual reconciliations, and seek detailed reporting on out-of-network spending. Policy actions at the federal and state levels, such as setting payment limits or tying reimbursements to Medicare rates, are also proposed as ways to better align incentives and protect both employers and employees.

Family Health Premiums Just Hit $27,000; Out-of-Pockets to Reach $21,200 in 2026

By Wendell Potter – We learned yesterday that the average cost of a family health insurance policy through an employer reached nearly $27,000 this year, 6% higher than what it cost in 2024. As if that weren’t alarming enough, researchers are predicting that the total likely will soar toward $30,000 next year because of rising medical costs and the unrelenting pressure insurers are under from Wall Street to increase their profits. Small businesses will be hit the hardest. Read Full Article...

HVBA Article Summary

1. Rising Health Insurance Costs Have Outpaced Inflation: Since 2014, the total cost of employer-sponsored family health insurance has risen by approximately 60%, and the employee share of premiums has climbed by 42%—outstripping both general and medical inflation. These increases mean that workers are paying significantly more each year just to maintain coverage, even though the overall value of that coverage has not improved proportionally.

2. Coverage Value Has Declined as Out-of-Pocket Burdens Grow: Although the Affordable Care Act implemented a cap on annual out-of-pocket costs, that cap has steadily risen—from $12,700 in 2014 to $21,200 in 2025. Meanwhile, deductibles, copays, and coinsurance have also increased. Many families now face higher personal spending before insurance benefits begin, and stricter insurer policies, like prior authorization requirements, are making it harder to access certain treatments and medications.

3. Insurer Profits Have Grown While Access to Care Diminishes: The seven largest for-profit health insurers have collectively earned hundreds of billions in profits since 2014. Their stock prices have seen substantial gains—well beyond those of the broader stock market. In contrast, coverage has become less accessible for small businesses and low- to middle-income individuals, many of whom depend on ACA marketplace subsidies that are now at risk of expiring. Without those subsidies, millions may lose access to affordable coverage.

Tirzepatide-Hormone Therapy Combo Tied to Weight Loss in Postmenopausal Women

By Jennifer Henderson – Postmenopausal women using hormone therapy (HT) saw significantly greater weight loss while taking the dual GIP/GLP-1 receptor agonist tirzepatide than their counterparts not using HT, according to a retrospective study. In the cohort study, total body weight loss (TBWL) at 18 months was evaluated for 160 women who were prescribed tirzepatide (Zepbound) for weight loss. Participants were evenly divided among four reproductive stages: Premenopausal, Perimenopausal, Postmenopausal with HT, Postmenopausal without HT. Ultimately, postmenopausal women using HT had the greatest TBWL at 19.9%, reported Regina Castaneda, MD, of the Mayo Clinic Florida in Jacksonville, at the Menopause Society annual meeting. Read Full Article...

HVBA Article Summary

1. Greater Weight Loss with Hormone Therapy: Postmenopausal women using hormone therapy (HT) experienced significantly greater total body weight loss (19.9%) after 18 months of tirzepatide treatment compared to those not using HT, who lost 15.6%. This suggests that HT may enhance the weight loss effects of tirzepatide in this population. The weight loss outcomes for HT users were similar to those seen in premenopausal and perimenopausal women.

2. Study Design and Limitations: The study was retrospective and included 160 women divided into four reproductive stages, matched for diabetes status, prior weight loss medication use, and baseline BMI. While the findings are promising, the retrospective nature means causality cannot be established, and further research is needed to confirm these results and understand the mechanisms involved.

3. Potential Mechanisms and Clinical Implications: Several hypotheses may explain the enhanced weight loss in HT users, including a healthy-user effect where HT users engage in healthier lifestyles, improved adherence to lifestyle interventions due to relief of vasomotor symptoms, and estrogen potentially amplifying the appetite-suppressing effects of GLP-1 medications like tirzepatide. Given the increased cardiovascular risk associated with menopause and obesity, these findings highlight the importance of considering hormone therapy in weight loss strategies for postmenopausal women.

How smart companies are revolutionizing benefits enrollment

By Alex Mechling – The fourth quarter is characterized as a time of renewal and change, as fall transitions into winter, and families and friends gather to celebrate and reflect on the past year and set their sights on the year ahead. For employers and their HR and finance teams, the fourth quarter is also a period of renewal and often change, for employee benefit programs. The majority of employers renew their benefit programs on January 1, with employees making benefit enrollment decisions. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Effective Communication Is Crucial for Benefits Participation: Even with significant investment in benefits programs, many employers fall short in driving employee participation due to a lack of clear, accessible, and timely communication. To counter this, HR leaders should deliver concise, actionable information through both digital and traditional channels. This includes early outreach, FAQs, side-by-side plan comparisons, and employee-friendly formats that help individuals understand their options and make informed decisions.

2. Simplification and Strategic Design Drive Engagement: Overwhelming employees with too many benefit options can reduce clarity and engagement. Employers should simplify plan offerings by focusing on two or three options that serve the majority of their workforce. Pairing this with a well-organized, transparent enrollment process — such as intuitive self-service tools and clearly explained changes — empowers employees to confidently navigate their choices, leading to improved participation and satisfaction.

3. Technology and Early Planning Improve Efficiency and Outcomes: Leveraging modern HR technology can transform open enrollment into a smoother, more strategic process. Centralized dashboards, automation, and employee self-service features not only streamline administration but also generate insights into employee preferences and resource usage. Starting communications early, ensuring legal compliance, and maintaining consistent outreach helps minimize last-minute issues and enhances both cost-efficiency and employee retention.