New Report: The Hidden Shift in ACA Health Plans

By Wendell Potter – A new report from No Patient Left Behind offers a sobering look at how health insurance plans sold on the ACA exchanges have changed in recent years. The analysis shows that since 2021, average out-of-pocket costs for prescription drugs have jumped by 36%. While research shows that premiums and deductibles may have come down, the data suggest that insurers are shifting more of the financial burden onto patients who are actually sick (especially those requiring medications). Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Increase in Out-of-Pocket Drug Costs: Since 2021, ACA marketplace plans have seen a striking 36% rise in average out-of-pocket spending on prescription drugs. The average enrollee paid $560 out of pocket for medications in 2023, compared to $412 two years earlier, while nearly 6% of enrollees paid more than $2,000 annually. This escalating cost burden disproportionately impacts sicker individuals who rely on ongoing treatment, undermining the intended financial protection health insurance is supposed to provide.

2. Cost-Shifting Practices by Insurers are Undermining Coverage: Even though insurers have lowered premiums and deductibles—making plans look more affordable—many have raised coinsurance and copays, increasing what patients actually pay when they get sick. This deceptive shift particularly harms those with chronic conditions who require regular medication, effectively making coverage more beneficial for the healthy and more burdensome for the ill. As a result, enrollees are exposed to high out-of-pocket risks at a time when they are least able to bear them.

3. Misleading Plan Labels and Opportunities for Reform: The report also highlights how confusing naming conventions, such as “Gold” plans, lead many working families to select coverage that seems more robust but may actually cost them more due to ineligibility for cost-sharing reductions. Silver plans, in contrast, often provide better financial protection when subsidies are applied. To address these systemic issues, the report recommends reforms like instituting a $2,000 out-of-pocket drug spending cap in ACA plans—matching Medicare Part D—and expanding state-based cost-sharing reductions to include Gold plans.

Stop-loss insurance costs rising faster than medical premiums

By Allison Bell – Benefits executives at Gallagher expect the cost of stop-loss insurance to rise faster than the cost of fully insured group health coverage next year. William Ziebell, the chief executive officer of the insurance broker's benefits and human resources consulting division, predicted Thursday that typical increases for stop-loss insurance will be somewhere in the mid-teens or higher. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Health Care Costs Across Categories: Employers are bracing for significant cost hikes: medical coverage is projected to climb in the higher single digits, while prescription drug coverage may increase in the lower double digits. Stop-loss insurance premiums are rising even faster, with some employers reportedly seeing renewal quotes of 20% or more, according to Aegis Risk’s survey. Additionally, the Business Group on Health projects employer health care costs overall could rise by 9% in 2026. These trends reflect the heavier financial burden employers must plan for in coming years.

2. Factors Driving Cost Growth: Multiple forces are pushing the underlying costs higher, including hospital workforce shortages, continued health care provider consolidation, and the growing use of very expensive specialty drugs. In stop-loss specifically, these pressures are amplified by the Affordable Care Act’s ban on annual or lifetime limits for essential benefits. This has led to more frequent large claims, with Ziebell noting cases reaching $2 million to $3 million or more are now “way up.”

3. Employer Strategies and Market Shifts: While the U.S. economy remains strong and the labor market resilient, many employers are shifting focus from attracting new employees to retaining talent while controlling health costs. Advisors may even find themselves recommending a return to fully insured group health coverage as an alternative. For self-insured employers, Gallagher consultants emphasize “point solutions,” such as removing large claimants from employer plans or securing better outside coverage, to offset the impact of stop-loss increases and maintain competitiveness in employee benefits.

CVS Health Subsidiary Omnicare Files for Bankruptcy After Civil Lawsuit Judgment

By PYMNTS – Omnicare, a CVS Health subsidiary that provides pharmacy services to skilled nursing facilities, independent and assisted living communities and other segments of the long-term care market, filed for bankruptcy Monday (Sept. 22). The company said in a press release that it attributed the move to recent litigation and added that it will also use this process to address other financial challenges facing the entire long-term care pharmacy industry. While doing so, Omnicare will evaluate the implementation of a standalone restructuring, a sale and other restructuring options, according to the release. Read Full Article...

HVBA Article Summary

1. Omnicare's Bankruptcy Filing: Omnicare, a subsidiary of CVS Health that provides pharmacy services to various long-term care markets, has filed for Chapter 11 bankruptcy citing a recent civil lawsuit judgment and other industry-wide financial challenges as motivating factors. The company is exploring different restructuring options, including a standalone restructuring and a potential sale, to manage its financial situation while continuing operations under court supervision.

2. Details of the Civil Lawsuit: The bankruptcy filing follows a $949 million civil judgment against Omnicare, related to allegations of improperly dispensing prescription drugs to long-term care patients. Omnicare is contesting this judgment after a federal judge denied their request to overturn it, with the company stating that the lawsuit involved technical violations of pharmacy law without allegations of harm to patients or denial of necessary medication.

3. Industry Context and Company Statements: CVS Health's leadership acknowledges ongoing industry pressures, including increased competition and rising costs, which have impacted Omnicare and its parent company. Despite bankruptcy proceedings, Omnicare's President David Azzolina emphasized the company's commitment to continue providing safe and reliable pharmacy services throughout the restructuring process.

New announcement on MHPAEA rules may mislead employers

By Natalie Miller and Laura Fischer – For more than four years, sponsors of group health plans have struggled to document – in a way that satisfies regulators – that their plans satisfy the nonquantitative treatment limitations (NQTLs) rules under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) as amended by the Consolidated Appropriations Act 2021 (CAA). A recent joint announcement from the U.S. Departments of Labor, Health and Human Services, and Treasury may have led sponsors to believe that those documentation requirements no longer apply. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. 2024 Final Regulations on NQTLs: The September 2024 rules introduced new compliance obligations for group health plan sponsors to ensure non-quantitative treatment limitations (NQTLs) are applied equally to mental health and substance use disorder benefits as they are to medical/surgical benefits. These obligations included fiduciaries preparing and executing certifications, creating a separate list of all plan NQTLs (effective starting with the 2025 plan year), and beginning data collection and evaluation processes to assess NQTL impacts in the 2026 plan year.

2. Non-Enforcement Decision: In May, federal agencies announced they will not enforce the additional compliance requirements established in the 2024 final regulations. This decision stems from ongoing litigation and an Executive Order directing deregulatory initiatives under the current administration. Importantly, while enforcement has been paused, the rules themselves remain intact—they have not been formally rescinded or altered, leaving future applicability subject to further governmental review and possible changes.

3. Ongoing Compliance Obligations: Despite the non-enforcement announcement, plans remain obligated to meet existing requirements under the Consolidated Appropriations Act (CAA). This includes conducting and documenting a thorough comparative analysis of NQTLs to demonstrate compliance with mental health parity rules. Regulators have emphasized that these obligations are still in force, and plan sponsors should remain attentive to developments, closely monitor regulatory updates, and prepare for potential shifts in enforcement priorities.

Where America's oldest residents live

By Alex Fitzpatrick – The number of centenarians — people aged 100 or older — in the U.S. grew by 50% from the 2010 Census to the 2020 count, per a new Census Bureau analysis. The Bureau's new deep dive offers a comprehensive look at one of America's fastest-growing demographics, who represent a triumph of medical and scientific advancements but also have unique caretaking needs. Read Full Article...

HVBA Article Summary

1. Significant Growth in Centenarian Population: The U.S. centenarian population increased by 50% from 53,400 in 2010 to about 80,100 in 2020, marking the largest census-to-census percentage increase in recent times. This growth reflects advancements in medical and scientific fields facilitating longer lifespans. The number of centenarians corresponds to approximately 2.4 individuals per 10,000 residents nationally as of 2020.

2. Geographic and Demographic Disparities: Hawaii, Rhode Island, and South Dakota have the highest centenarian rates relative to their populations, while Utah, Alaska, and Nevada have the lowest. Additionally, 78.8% of U.S. centenarians are female, highlighting the ongoing life expectancy gender gap. The centenarian group is becoming more racially diverse, with the proportion identified as 'white alone' decreasing from 82.5% in 2010 to 74.6% in 2020.

3. Data Challenges and COVID-19 Impact: The reported numbers do not fully capture the impact of the COVID-19 pandemic, which disproportionately affected older populations, especially before vaccines were available. Collecting accurate data on centenarians is complex due to misreporting, proxy reporting, and data capture errors, which can affect the reliability of census findings. Despite these challenges, the overall trend suggests Americans are living longer than before.

Benefit managers share their 7 open enrollment best practices

By Alyssa Place – Open enrollment is no longer just a compliance exercise — it's a strategic opportunity to strengthen employee engagement, address generational needs and demonstrate the value of your organization's total rewards. With shifting demographics, new technologies, and growing financial pressures, benefit leaders must adapt their strategies to meet employees where they are, while navigating new challenges and budget constraints. Leaders will have to consider three key areas this season: Affordability, engagement and education, says Todd Katz, head of group benefits at MetLife. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Open enrollment is evolving beyond compliance to a strategic function: Employers are using this period to boost employee engagement, respond to diverse generational needs, and showcase the overall value of employee benefits and total rewards packages. This shift is driven by changing demographics, new technological tools, and mounting financial pressures that require adaptive strategies.

2. Effective communication and tailored benefits are crucial: Addressing the unique priorities of different generations, simplifying messaging to avoid jargon, and providing accessible decision-making support can improve employees' understanding and utilization of benefits. Personalizing benefits education and using multiple communication channels enhance employee engagement and satisfaction.

3. Leveraging technology and regulatory clarity supports success: AI-powered tools help employees navigate benefit choices more easily while providing HR leaders with useful insights. Additionally, benefit managers must clearly communicate benefits amidst complex regulatory and economic environments, including upcoming compliance with regulations like OBBBA, to help employees feel financially secure during uncertain times.

Bill targets UnitedHealth, aims to break up insurer-owned clinics

By Kristen Smithberg – New legislation proposed by Congressional democrats aims to limit the ability of large insurance companies to acquire independently owned clinics and health practices. The Patients Over Profits (POP) Act specifically singles out UnitedHealth Group and its Optum subsidiary. The act is led by senators Jeff Merkley and Elizabeth Warren, along with representatives Val Hoyle, Pat Ryan and Pramila Jayapal. Sen. Edward Markey and Rep. Alexandria Ocasio-Cortez co-sponsored the bill. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Legislative Aim to Curb Vertical Integration: The Patients Over Profits (POP) Act seeks to prevent large insurance companies like UnitedHealth Group and its Optum subsidiary from acquiring independent clinics and health practices. The bill cites that Optum has made $31 billion in acquisitions over two years, and its parent company has acquired over 100 surgery centers in 2024 alone, signaling growing monopolization of care delivery systems.

2. Wide-Ranging Impacts and Concerns: The legislation highlights numerous risks tied to insurer ownership, including loss of physician autonomy, reduced care quality, and inflated prices. Supporters note that Optum now owns 750 clinical subsidiaries and contracts with 10% of U.S. doctors, driving concerns that profit-seeking motives are replacing local patient care priorities and worker compensation.

3. Provisions and Enforcement: The POP Act prohibits insurer ownership of Medicare Part B and C providers and mandates divestment from existing holdings. If these companies fail to comply, enforcement actions could come from the FTC, DOJ antitrust division, the HHS Inspector General, and state attorneys general—part of an effort to make such vertical integration models less financially attractive.