As Federal Government Hurtles Towards a Shutdown, Telehealth Is Endangered

By Mark Hagland – On Tuesday, September 30, as the impasse in Congress over budget priorities rolled forward, and the nation lumbered towards a federal government shutdown at midnight eastern time [EDITOR'S NOTE: The shutdown began at 12 midnight eastern time on Wednesday], hospital-at-home and other telehealth programs were in a particular spotlight, as reimbursement for remotely delivered care needed to be renewed by Congress, and was not automatic. Read Full Article...

HVBA Article Summary

1. Medicare Telehealth and Hospital-at-Home Programs Face Expiration Without Congressional Action: Millions of seniors who rely on telehealth appointments and in-home hospital-level care could lose access to these services if Congress fails to extend the temporary waivers enacted during the COVID-19 pandemic. These programs, which have become essential for many older Americans—especially those with limited mobility—require proactive legislative renewal, and are currently at risk due to stalled budget negotiations and the threat of a government shutdown.

2. Potential Impact on Patients and Providers: If the waivers expire, Medicare will revert to more restrictive pre-pandemic telehealth rules, which limit coverage based on geographic location, provider type, and visit format. This change could disrupt access for over 6 million seniors who used telehealth last year and place financial strain on healthcare providers who risk not being reimbursed for care delivered during any lapse. For patients unable to attend in-person visits, this could mean missing or delaying critical care, especially in densely populated areas.

3. Bipartisan Support Exists, But Timing is Critical: Both Republican and Democratic lawmakers have introduced proposals to extend telehealth and hospital-at-home services, reflecting widespread bipartisan support. The main difference lies in how long these extensions would last—ranging from October to November 2025. However, unless Congress acts swiftly, even a short-term lapse could create logistical chaos, confusion for patients, and financial uncertainty for providers. It also remains unclear whether any coverage gap would be addressed retroactively if legislation passes after the expiration.

ERISA doesn't preempt Arkansas PBM reporting law, court rules

By Alan Goforth – The Employee Retirement Income Security Act does not preempt an Arkansas state law that requires ERISA plans to report certain compensation information about their pharmacy benefit managers, an Illinois district court ruled in Central States, Southeast and Southwest Areas Health and Wellness Fund et al. vs. McClain. Rule 128 from the Arkansas Insurance Department provides state-level regulation of PBMs and mandates that health benefit plans and health care payers disclose information that is used to determine if pharmacy compensation programs are “fair and reasonable.” Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. District Court Upholds State PBM Reporting Requirements: The Illinois district court determined that Arkansas’s Rule 128, which requires disclosure of pharmacy benefit manager (PBM) compensation by health plans, is not preempted by ERISA. The court found that the regulation applies broadly and does not exclusively target ERISA plans, which was a key factor in its decision. This outcome affirms the ability of states to impose certain reporting and transparency obligations on PBMs and health plans operating within their jurisdiction.

2. Employers Must Remain Vigilant About State PBM Laws: The ruling highlights that employers, especially those with self-funded health plans, should not automatically assume exemption from state PBM regulations due to ERISA. Legal experts recommend that employers closely track ongoing developments and carefully assess the applicability of state PBM laws to their prescription drug plans. Proactive compliance with state reporting requirements may be prudent, even as legal interpretations continue to evolve.

3. Legal Uncertainty and Potential for Further Appeals: While this decision supports state-level PBM regulation, the legal landscape remains unsettled, with courts across the country divided on ERISA preemption issues. The possibility of appeals or eventual Supreme Court review means that the regulatory environment could shift further. Employers and plan sponsors are advised to monitor future case developments and be prepared to adjust compliance strategies as new guidance emerges.

3 strategies to manage healthcare cost increases in your benefit plans

By Paola Peralta – Healthcare costs are nearing double-digit increases, but benefit managers can make smart adjustments to their plans to brace for the impact. Employers are predicting a 9% increase in healthcare costs for 2026, according to a recent Business Group on Health survey — the largest annual jump in more than a decade. Revisiting and redesigning health plans may be the most effective way for organizations to protect both their bottom line and their workforce from the coming surge. "It's a very challenging environment for employers," says Eric Miller, VP and consulting actuary at Segal. "They will need to evaluate their networks and look for ways to mitigate cost trends and achieve hard dollar savings while still doing everything to improve the health and well-being of their population." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Healthcare Cost Drivers: The increase in healthcare costs is primarily driven by three factors: a rise in GLP-1 prescriptions for weight loss, increased use and higher provider costs for mental health services, and price hikes for hospital stays, surgeries, and doctor visits. The National Institute predicts a 9-11% rise in prescription drug spending for 2025, while nearly 30% of Americans now use mental health services, up from 22% in 2019. Provider shortages give hospitals and doctors more leverage to negotiate higher payments, directly contributing to rising healthcare expenses.

2. Strategies for Cost Management: Benefit managers can implement targeted plan redesigns to manage rising costs effectively. Custom drug plan designs that prioritize less expensive alternatives to popular brand-name weight loss medications can reduce spending. Leveraging technology to identify members at risk for chronic conditions allows for preventive care that can avoid costly emergency claims, creating a win-win scenario of improved health outcomes and cost savings.

3. Long-Term Solutions and Data Utilization: Some organizations may benefit from longer-term strategies such as onsite clinics, which can reduce emergency room, urgent care, and specialist visits by improving access to care. The return on investment for such clinics tends to increase over time as they mature. Collecting and analyzing workforce health data is crucial for negotiating with providers and selecting plans with optimal in-network options, especially as price inflation trends are expected to persist in the near future.

340B rebate pilot would cost hospitals $400M: AHA

By Paige Twenter – If HHS’ 340B rebate model pilot proceeds as planned, more than 2,700 U.S. hospitals will collectively be saddled with approximately $400 million in operational costs and 11.2 million labor burden hours, according to the American Hospital Association. The rebate model, slated to go into effect Jan. 1, will allow drug manufacturers that are part of CMS’ first cycle of negotiated drug prices to provide rebates — rather than upfront discounts — for 340B entities. Congress established the 340B program in 1992 to require drugmakers to sell specific outpatient drugs to eligible providers at discounted prices. Read Full Article...

HVBA Article Summary

1. Significant Cost and Administrative Burden: The Health Resources and Services Administration (HRSA) estimates that implementing its 340B pilot program will require over 1.5 million labor hours for regulatory compliance. According to the American Hospital Association (AHA), this would result in substantial operational costs for hospitals—ranging from $150,000 to $500,000 per facility—culminating in a projected $400 million total burden across all 340B hospitals nationwide.

2. Strong Pushback from Hospitals and Lawmakers: The AHA has voiced serious concerns about the pilot’s short implementation window and the disruptive impact it may have on the 340B program’s long-standing operations. Health system leaders warned that the program could become an “administrative and operational nightmare.” Additionally, a bipartisan coalition of 162 legislators has criticized the pilot's design, timeline, and potential consequences, urging HRSA to reconsider its approach.

3. Emerging Conflict with Drug Manufacturers: In late 2024, several pharmaceutical companies introduced a proposal for a rebate-based payment model within the 340B program, claiming it would enhance transparency and lower costs for patients. However, this triggered a complex legal and regulatory battle involving drug manufacturers, HRSA, and participating 340B hospitals, further complicating the program’s future direction and raising concerns about its stability.

The more financial savvy women possess, the less satisfied they are with their benefits, study finds

By Emma Beavins – Generally, women reported lower confidence levels than men in understanding finances, benefits and insurance, The Standard found. Yet, two-thirds of women are the primary benefits providers in their households. For example, 66% of women said they’re knowledgeable about their benefits, compared to 74% of men. When it comes to insurance, 65% of women said they felt confident about their understanding, while 74% of men said the same. Read Full Article...

HVBA Article Summary

1. Tailored Benefits Education Empowers Women: Employers have a strategic opportunity to better engage and support women by offering benefits education programs specifically designed around their unique needs and life situations. These programs not only help women make more informed and confident choices regarding their health, finances, and family responsibilities but also contribute to a more inclusive and equitable workplace culture.

2. Customized and Flexible Benefits Aid Retention: The study highlights that nearly three-quarters of employees would be more inclined to stay with a company that provides benefits aligned with their individual circumstances. By offering flexible, customizable benefits—especially those that account for the diverse needs of women—organizations can enhance employee satisfaction, strengthen loyalty, and improve both recruitment and retention outcomes.

3. Caregiving Support is Increasingly Critical: With a growing number of workers belonging to the “sandwich generation”—those simultaneously caring for children and aging parents—there is an urgent need for companies to offer caregiving-related benefits, such as leave policies and support programs. Addressing these real-life pressures not only helps ease employee stress but also signals that the company values work-life balance and is committed to long-term employee well-being.

White House announces new prescription drug website, TrumpRx

By Heather Landi – The White House announced Tuesday it was rolling out a direct-to-consumer website where individuals can buy prescription medications at discounted prices rather than through insurance. The new website, called TrumpRx, was unveiled as part of the Trump administration's broader effort to implement a “most favored nation” (MFN) pricing model for prescription drugs, meaning the U.S. pays no more than the lowest prices charged in other wealthy countries. Read Full Article...

HVBA Article Summary

1. Introduction of TrumpRx Website: The White House has launched TrumpRx, a direct-to-consumer website designed to allow individuals to purchase prescription medications at discounted prices without using insurance. This initiative is part of the Trump administration's effort to apply a 'most favored nation' pricing model, ensuring the U.S. pays no more than the lowest prices charged in other wealthy countries. The website will be government-operated but will direct patients to manufacturers’ own direct-to-consumer sites rather than selling medications directly.

2. Pfizer's Role and Pricing Agreements: Pfizer has agreed to provide all its prescription drugs on Medicaid at reduced MFN pricing and to offer many drugs at significant discounts through TrumpRx.gov, with savings averaging around 50% and reaching up to 85%. The majority of Pfizer’s primary care treatments and select specialty brands will be available on the site. This deal comes amid pressure on pharmaceutical companies to lower drug prices under the MFN campaign.

3. Industry and Expert Reactions: The Pharmaceutical Care Management Association supports the administration’s goal to reduce drug costs but blames high prices on pharmaceutical companies. Conversely, the National Association of Chain Drug Stores criticized pharmacy benefit managers (PBMs) for inflating drug costs and warned that the new government-run DTC website could compete with traditional pharmacies, which are vital healthcare access points. Health policy experts have expressed skepticism about the impact of direct-to-consumer sales on lowering costs for the average person.

How AI-powered technology differentiates benefits advisors

By Anupam Gupta – The employee benefits industry is crowded and competitive. Employers are inundated with proposals, products and promises from brokers and benefits advisors all claiming to offer the best solutions for their people and their bottom line. Yet to many HR leaders, brokerages can appear nearly identical — each offering access to similar carrier networks, quoting comparable products, and touting service as their main differentiator. That reality makes it increasingly difficult for advisors to stand out. At the same time, employers are demanding more. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Technology as a Differentiator: The article emphasizes that in a crowded benefits marketplace, technology is the key factor that can set benefits advisors apart. Traditional fragmented systems create inefficiencies and data silos, limiting advisors' ability to provide high-value service. Modern brokerages adopting unified management systems integrated with AI can streamline operations and improve client engagement, enabling advisors to deliver a seamless and consultative experience.

2. AI Enhances Advisory Capabilities: AI-powered tools transform raw data into actionable insights, helping advisors identify coverage gaps, optimize costs, and provide proactive recommendations. Automation features such as AI-generated email summaries and content creation reduce manual workload and improve communication efficiency. This continuous, year-round engagement fosters trust and positions advisors as strategic partners rather than just annual vendors.

3. Operational Efficiency and Future Opportunities: AI-driven automation extends beyond client interaction to finance workflows, such as automating commission reconciliations that typically consume significant staff time. By embedding AI within management systems, brokerages can reduce errors, save time, and maintain compliance. Agencies that leverage these technologies effectively will enhance productivity, deepen client relationships, and gain a competitive edge in the evolving benefits industry.