Bipartisan Bill Would Codify, Strengthen Price Transparency Rules

By Luke Gale – Legislation proposed in the Senate would codify and significantly expand federal price transparency rules. The Patients Deserve Price Tags Act, introduced by Senators John Hickenlooper (D-Colorado) and Roger Marshall, MD (R-Kansas) , aims to increase transparency around healthcare prices by establishing new requirements for virtually all healthcare stakeholders and creating stronger mandates for federal agencies to enforce compliance. Read Full Article...

HVBA Article Summary

1. Expansion and Enforcement of Price Transparency for Providers: The proposed legislation aims to strengthen existing price transparency regulations by codifying the current Hospital Price Transparency Final Rule and extending its scope to additional care settings such as ambulatory surgical centers. Providers would be required to disclose specific prices rather than estimates, ensuring greater clarity for patients. To enforce compliance, the Department of Health and Human Services (HHS) would conduct annual audits of hospitals, with noncompliant facilities facing daily monetary penalties ranging from $300 for small hospitals to over $10,000 for large ones.

2. New Requirements for Payers and Pharmacy Benefit Managers (PBMs): The legislation introduces federal mandates for health insurers to develop and maintain real-time price comparison tools. These tools must accurately display a patient’s actual, out-of-pocket costs for any medical service or item from participating providers, reflecting their individual insurance benefits. Additionally, PBMs and third-party administrators would be obligated to submit biannual reports to health plan fiduciaries, including detailed information about prescription drug costs, fees, and overall spending—providing employers and other stakeholders with greater insight into pharmacy benefit structures.

3. Legislation Responds to Systemic Concerns About Healthcare Cost Opacity: Motivated by growing frustration over the lack of price transparency in healthcare, the legislation seeks to address systemic issues identified by expert testimony in recent Senate hearings. It reflects a shift in policy focus by placing more responsibility on payers to deliver accurate pricing information directly to patients. This could relieve some of the administrative burden on providers, who often struggle to generate accurate estimates due to inconsistent or non-standardized data from payers. By mandating standardized tools and reporting, the bill attempts to bring more consistency and accountability to healthcare billing practices.

Aetna faces court setback over alleged mental health parity violation

By Allison Bell – A new federal court ruling could push employers to take a new look at their health plans' behavioral health coverage exclusions. U.S. District Judge Ted Stewart suggested in a memorandum decision released Tuesday that an employer health plan might have violated the federal Mental Health Parity and Addiction Equity Act by listing an exclusion for "wilderness treatment programs" in the residential treatment facility coverage description in the behavioral health section but not in the medical/surgical section. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Partial Continuation of Lawsuit Based on Parity Act: A federal judge allowed part of a lawsuit to proceed against Aetna and others after finding it plausible that the insurance plan applied different standards for behavioral health care compared to medical/surgical care—potentially violating the Mental Health Parity and Addiction Equity Act (MHPAEA). The issue centers on an exclusion of wilderness therapy from behavioral health coverage.

2. Request for Wilderness Program Reimbursement Dismissed: Although the plaintiffs sought $77,000 in coverage for a minor’s stay at the blueFire Wilderness Therapy program, the judge dismissed this specific request. The plan only covers behavioral health services delivered by legally authorized health care providers—not programs like blueFire.

3. Broader Legal Context and Industry Reactions: The case reflects a broader national trend, with multiple lawsuits challenging insurance exclusions for certain mental health treatments. Plaintiffs’ attorneys claim such exclusions often violate parity laws. CVS Health and MITRE, involved in the case, emphasized support for behavioral health care but declined to comment in detail, citing the early stage of litigation.

CMS expands eligibility for catastrophic health plans

By Jakob Emerson – CMS is expanding eligibility for catastrophic health coverage on the ACA marketplace in 2026. The agency issued new hardship exemption guidance on Sept. 4 aimed at individuals projected to be ineligible for advance premium tax credits or cost-sharing reductions due to their annual household income. Read Full Article...

HVBA Article Summary

1. Hardship Exemption Expansion: Consumers who are not eligible for Affordable Care Act (ACA) premium subsidies will now qualify for a hardship exemption. This change allows them to purchase catastrophic health insurance plans, which were previously limited in availability, either through the ACA exchange or directly from insurers. This aims to offer a lower-cost alternative for those who might otherwise be priced out of coverage.

2. Expected Premium Increases: In anticipation of the expiration of enhanced premium tax credits at the end of 2025 and in response to steadily rising healthcare costs, insurers across the country have proposed a median premium rate hike of 15% for 2026. This signals a potentially significant increase in costs for consumers who rely on marketplace coverage.

3. CMS Policy and Enrollment Changes: The Centers for Medicare & Medicaid Services (CMS) is implementing policy updates to improve affordability and simplify access to catastrophic plans. These plans, which cover all essential health benefits and offer preventive services with no cost-sharing, are typically available only to people under 30. Starting November 1, CMS will streamline the application process to make these plans more accessible to a broader population, especially those without access to subsidies.

Employers prepare for the highest health benefit cost increase in 15 years 

By Mercer – If employer health plan sponsors hoped that 2026 would bring some relief from the recent upward trend in cost growth, they are now having to face up to a very different reality. The total health benefit cost per employee is expected to rise 6.5% on average in 2026 — the highest increase since 2010 — even after accounting for planned cost-reduction measures. Employers estimated that plan cost would increase by nearly 9%, on average, if they took no action to lower cost. Read Full Article...

HVBA Article Summary

1. Health Benefit Costs to Rise Again in 2026: Mercer’s survey of over 1,700 U.S. employers indicates that 2026 will mark the fourth consecutive year of above-average growth in employer-sponsored health plan costs, continuing a trend that followed a decade of modest 3% annual increases. The rise is fueled by both higher prices — due to advanced therapies, provider consolidation, and healthcare wage inflation — and increased service utilization, especially in areas like behavioral and virtual care.

2. Employers Focus on Both Cost Control and Long-Term Strategies: In response to rising costs, 59% of employers plan to implement cost-cutting changes in 2026, up from 48% in 2025 and 44% in 2024. While many will adjust deductibles and cost-sharing, a growing number are also investing in longer-term strategies such as managing high-cost claims and measuring program value. Notably, nearly two-thirds of large employers are prioritizing expanded access to behavioral healthcare.

3. Employees Will Face Higher Costs and More Plan Options: With projected plan cost increases of 6–7% in 2026, employees are expected to see higher premium contributions and, in many cases, increased out-of-pocket costs. Employers are encouraged to guide employees through plan choices — particularly as over one-third of large employers intend to offer non-traditional plans like high-performance networks or variable copay models, which may offer savings but require more informed decision-making.

Long-term care crisis looms as just 3% of Americans over 50 have insurance

By Kristen Smithberg – The need for long-term care (LTC) services is expected to be substantial for people over age 65, but only 3% of Americans over the age of 50 have any LTC insurance protection, according to a LIMRA analysis. This gap is of growing concern as a large number of Americans are reaching age 65 at a time when LTC costs have skyrocketed. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. High Likelihood and Costs of Long-Term Care (LTC): According to the Department of Health & Human Services, a majority (56%) of Americans are expected to require some form of long-term care, with nearly half needing paid services. A significant portion—14%—will face out-of-pocket expenses exceeding $100,000. The growing cost of LTC, such as over $77,000 annually for home health aid and up to $127,000 for a semi-private nursing home room, poses a financial challenge for many families.

2. Caregiving Burden Drives Interest in Insurance Solutions: As LTC costs rise, caregiving responsibilities are increasingly falling on families, especially among the “sandwich generation” who care for both children and aging parents. Over 70% of caregivers report that their experiences have influenced their own planning for future care. This has led to greater interest in LTC insurance, particularly among younger generations seeking to avoid becoming a burden to their loved ones.

3. Shift from Standalone LTC Insurance to Hybrid Products: Due to rising costs and subsequent premium hikes, the standalone LTC insurance market has declined significantly, with most carriers exiting by 2012. In response, the industry has shifted toward combination products (e.g., life insurance with LTC benefits), which appeal to a broader, younger demographic and middle-income consumers. However, insurers still face challenges in actuarial modeling due to limited claims data.

PhRMA launches ad campaign urging Congress to address '340B medicine mark-ups'

By Dave Muoio – The pharmaceutical lobby is ramping up its opposition to nonprofit health systems’ expanding use of the 340B Drug Discount program with the launch of an advertising campaign describing the subsidies as “a hidden tax on patients, employers and taxpayers.” Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. PhRMA Campaign Criticizes 340B Program Abuse by Hospitals: The Pharmaceutical Research and Manufacturers of America (PhRMA) launched a seven-figure ad campaign called “Meet Mark” to highlight what it describes as hospital abuse of the federal 340B drug discount program. The campaign accuses certain nonprofit hospitals of marking up discounted drugs excessively and using the profit for financial gain, rather than passing savings to low-income patients.

2. Ongoing Dispute Between Drugmakers and Hospitals Over 340B Usage: Drug manufacturers argue that the expanded use of 340B has strayed from its original intent, with large nonprofit health systems allegedly profiting from discounts meant for safety-net providers. In contrast, hospitals and provider organizations contend that the program is vital for maintaining care access amid rising operational costs, especially in rural or underserved areas.

3. Growing Legislative and Policy Scrutiny of the 340B Program: Momentum appears to be shifting in favor of pharmaceutical companies. A recent Senate report called for reforms aimed at increasing transparency and oversight. Additionally, the Trump administration has announced a 2026 pilot program to test drug rebate models previously proposed by drugmakers, although hospital groups like the AHA have criticized these efforts as flawed and burdensome.

How to navigate soaring stop-loss rates

By Gerardo Zampaglione – Benefits advisors and self-funded clients are entering a challenging renewal season. "Stop-loss premium increases in 2026 are likely to be the biggest in recent memory, and it's because of increasingly frequent and severe high-dollar claims," Richard Fleder, a longtime investor and executive in the self-funded space, recently told me. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Growth Reflects Cost Pressures, Not Market Health: The stop-loss insurance market grew by 12% in 2024, reaching $35.4 billion in annual premiums. While this double-digit increase may seem positive at first glance, it is primarily driven by rising healthcare costs and the growing frequency of million-dollar claims—rather than by stronger market fundamentals. This trend signals a system under financial pressure, with employers and insurers reacting defensively to unsustainable cost trajectories rather than benefiting from improved risk performance.

2. Rising Claims Are Reshaping Underwriting and Plan Design: The escalating number and size of high-cost claims—up 29% year-over-year and 61% over four years—are fundamentally altering how self-funded health plans are underwritten and priced. As a result, the industry is experiencing a shift toward tighter underwriting margins, increased deductibles, more frequent use of “laser” exclusions, and complex coverage provisions. These developments are creating operational and financial strain across the ecosystem, from third-party administrators to captive managers and benefits advisors, all of whom must now adapt to a more volatile and complex claims environment.

3. Strategic Financial Design and Flexibility Are Crucial for Resilience: In response to the hardening stop-loss market, the article highlights the need for a proactive, strategic approach to financial planning. Benefits advisors are encouraged to move beyond reactive risk mitigation and adopt adaptive capital planning—emphasizing liquidity, scenario modeling, and early data analysis. By exploring a wider array of carriers and funding models, employers can build more resilient plans that withstand large claims without compromising long-term financial health. Flexibility, collaboration, and transparency are portrayed as essential tools for navigating an increasingly unpredictable stop-loss landscape.