The MOC Brief: self-funded health plan news, every issue

In this issue

1. BENEFITS BENCHMARK KFF's benchmark survey lands, and the worker's contribution outran the premium.
2. PREMIUM DRIVERS A federal brief ties state hospital taxes to higher employer premiums.
3. CLAIMS FRAUD Prosecutors charge 15 people across several schemes, the largest billing private insurers $1.6 billion.
4. SPECIALTY DRUG PRICING Median net launch prices sit near $257,000, and a quarter of 2025 launches ran far higher.
5. PRIOR AUTHORIZATION TECHNOLOGY Five employers ask CMS and health plans to extend electronic prior authorization to self-funded plans.

In this issue

1. CLAIMS COST TREND Per-person spending for under-65 employer coverage rose 18.8 percent from 2019 to 2023, almost all of it price.
2. FIDUCIARY LIABILITY A company owner is personally liable for employee contributions he withheld, plus the claims his plan denied.
3. NETWORK TIERING A 750,000-member plan will move a hospital system out of network on January 1, 2027.
4. INDIVIDUAL COVERAGE HRAS ICHRAs are now CHOICE Arrangements, and CMS is promoting them to employers.
5. SURPRISE BILLING ARBITRATION CMS says surprise billing arbitration costs keep climbing and the federal filing portal is being replaced.

In this issue

1. FIDUCIARY LITIGATION An appeals court overruled its own 1985 exhaustion rule for ERISA statutory claims
2. PREMIUM TAX CREDITS Treasury proposed a narrower premium tax credit and set a December hearing
3. TPA COMPETITION Michigan's complaint says plan sponsors pay more when only one Blue plan can bid
4. 340B PRICING Ten drugmakers move 340B from an up-front discount to a rebate claimed after the dispense
5. PRIOR AUTHORIZATION UnitedHealthcare drops pediatric prior authorization on select codes, with a UMR plan exclusion

In this issue

1. PLAN ADMINISTRATORS Members can sue the company that administers their claims
2. PRICE DATA DEADLINES Three price file publication dates, and the schemas are not ready yet
3. RENEWAL BENCHMARK North America's 2027 trend now sits above Aon's global average
4. CLAIMS CODING Hospitals and the Blues are fighting over what AI coding costs you
5. SITE OF SERVICE A large TPA just retired two site of service reviews

In this issue

1. Price Data Hospitals posted a zero allowed amount count on 95 percent of commercial entries priced as a percentage of charges.
2. PBM Oversight A federal audit measured what four vertically integrated Part D sponsors route to pharmacies they own, about 28 percent of volume.
3. Payer AI Cigna will start rolling out an AI care guide in early 2027 and projects a 10 percent cut in inefficient spending by 2030.
4. Network Contracts Sentara ended Anthem talks on three plan lines and says employer coverage is still being negotiated.
5. Program Integrity A federal fraud task force and OPM reported $237.7 million in carrier-reported savings stopped before claims were paid.

In this issue

1. Price Transparency Federal regulators finalized the price transparency rules, and your plan must name the officer who answers for its data.
2. Hospital Contracts Three self-funded union plans got past dismissal against a hospital system over its gag and all-products clauses.
3. Digital Health Most employers tie digital health fees to performance, and 38 percent of purchasers cannot verify the results.
4. Plan Communications A court let a widow pursue a money remedy against an employer over what the employer did not tell her.
5. Plan Assets A benefits administrator's chief executive pleaded guilty to taking $8.8 million clients sent his firm to pay carriers.

In this issue

1. Employer Contributions Trump account rules took effect September 30, and employers may now contribute
2. Renewal Benchmark Federal 2027 health premiums are set, and the enrollee share rises faster than the total
3. Site of Service Elevance will check hospital bills against hospital addresses before paying the hospital rate
4. Pharmacy Formulary Two of the three largest PBMs have posted 2027 exclusions, and the third's page shows nothing past 2026
5. Prior Authorization Prior authorization burden rose while two other physician burdens fell

In this issue

1. BENEFIT PARTICIPATION BLS measured that 65 percent of private industry workers offered a medical plan took it in March.
2. SITE OF CARE EBRI priced the same physician-administered drug far higher in a hospital outpatient department.
3. COST TREND Altarum put health care prices at 2.5 percent in August and utilization growth at 4.1 percent in July.
4. PREVENTIVE COVERAGE GAO reviewed how Labor and the states police contraceptive coverage rules.
5. PLAN CONTRACTS The Fifth Circuit heard argument on whether a plan can sue its administrator in court.

In this issue

1. PHARMACY CONTRACTING CMS is asking how far Part D pharmacy rates are set by reference to a pharmacy's own commercial rates, and you can file a comment.
2. OUT-OF-NETWORK DISPUTES A federal judge dismissed a health plan's suit over arbitration eligibility for lack of jurisdiction.
3. CLAIMS TECHNOLOGY The federal arbitration filing system is moving to a new platform, and the organization handling your disputes has to register.
4. DRUG PURCHASING TrumpRx, the federal cash-price drug site, beat the peer-country average on 17 of 32 brand drugs, and the big PBMs have agreed to show patients those prices.
5. PBM DISCLOSURE A House bill would make your broker or consultant restate every PBM bid as one total annual cost figure under ERISA.

In this issue

1. HEALTH PLAN AI A public plan sponsor put five artificial intelligence limits on the carriers that administer its health plans.
2. OUT-OF-NETWORK DISPUTES Providers won 86.4 percent of disputed surprise billing line items in 2025, at a median of 3.9 times the plan's benchmark rate.
3. MEDICAL INFLATION Consumer medical inflation ran 1.6 percent over the year, nowhere near your renewal quote.
4. PREVENTIVE COVERAGE Eight new appointments to the panel whose ratings set which preventive services your plan covers with no cost sharing.
5. DELAYS AND DENIALS Half of employer plan members with multiple conditions say their insurer denied or delayed prescribed care within two years.

In this issue

1. BENEFIT COSTS Employers now spend more than twice as much per hour on health benefits as on retirement.
2. HOSPITAL CONSOLIDATION Hospitals ask regulators to look past commercial prices in merger review, because commercial patients are 40 percent of hospital days.
3. MEMBER FINANCES Among workers reporting severe difficulty after a medical event, 63 percent were still in difficulty.
4. PAYMENT INTEGRITY Private insurers were among the payers in $17.5 billion of suspicious health care money.
5. PLAN DESIGN The federal government's personnel agency asks whether 132 plan options serve enrollees better than fewer would.

In this issue

1. STOP-LOSS Stop-loss renewal increases rose again in 2026, and the higher your deductible the steeper the increase.
2. PRIOR AUTHORIZATION UnitedHealthcare pulls prior authorization off a long list of codes next month.
3. DRUG SAFETY A new FDA boxed warning lands on an infusion drug, and the monitoring test is rarely run.
4. PREMIUM ECONOMICS A study explains 91 percent of premium growth by spending, and leaves self-funded plans out.
5. HEALTH DATA The FTC withdrew its 2021 guidance on health app breaches, and its breach notification rule still stands.

In this issue

1. ERISA LITIGATION Your administrator's defense may be that you never audited it
2. VENDOR FEES RAND names the shared savings fee employers cannot see
3. CLAIMS AUTOMATION A House bill would write AI denial limits into ERISA
4. SPECIALTY MONITORING The FDA approved camizestrant with a companion test attached
5. PLAN FRAUD A medical equipment scheme sent statements for equipment nobody delivered

In this issue

1. Cost Trend The 2027 cost projection your CFO will ask about, and the 11 percent it would be without plan changes
2. Plan Notices A new email delivery safe harbor for health plan notices, and a short comment window
3. Claims Friction Hospitals told state regulators that collecting from insurers cost them $43 billion in 2025
4. Network Access A network contract that runs out September 30, and the question it asks about yours
5. Dependent Care A new 90 percent safe harbor for dependent care testing, and a comment window closing this month

In this issue

1. Arbitration Costs What four years of surprise billing arbitration has cost, and who is filing
2. PBM Preemption A federal appeals court lets a state order your plan to pay pharmacies more
3. Wellness Rules Three agencies stop enforcing retroactive wellness rewards, so you can prorate
4. Diabetes Drugs Mounjaro's new cardiovascular indication reaches your prior authorization file
5. Records Access A $50,000 HIPAA settlement, and the clock that runs against your plan

In this issue

1. Cost Trend What large employers are budgeting for 2027, and what plan design takes back
2. PBM Antitrust Florida sues Prime Therapeutics and Express Scripts over pharmacy reimbursement
3. Cancer Spend A first-in-class pancreatic cancer drug lengthens the most expensive claims you pay
4. Telehealth Access The DEA's telehealth special registration rule reaches OMB for final review
5. Provider Consolidation The FTC finalizes seven surgery center divestitures in a $3.9 billion deal

In this issue

1. PLAN LIABILITY Two circuits split on whether a TPA's verification call is your liability
2. TPA ACCOUNTABILITY A self-funded employer's fiduciary case against its own TPA survives dismissal
3. DRUG COMPETITION The FTC says buying patent applications is reachable under antitrust law
4. MEMBER AFFORDABILITY Only 28 percent of employees feel ready for an unexpected $1,000 expense
5. PREVENTIVE COVERAGE HHS opens comment on the vaccine categories behind first-dollar coverage

In this issue

1. Cost Trend Aon projects a 9.5 percent employer cost increase for 2027
2. Pharmacy Spend Biosimilar switching saved plans thousands and members nothing
3. Prior Authorization Epic turns on real time prior authorization five months early
4. Pharmacy Integrity A GLP-1 scheme ran on 60 stolen physician identities
5. PBM Transparency The PBM fee disclosure rule sits at the White House

In this issue

1. PHARMACY COVERAGE Business Group on Health finds 28 percent of employers covering GLP-1s for weight management will not commit to continuing in 2027.
2. DRUG PRICE TREND Prescription drug prices fall 3.1 percent over twelve months while medical care services rise 2.7 percent.
3. SITE OF CARE CMS proposes requiring every off campus hospital outpatient department to obtain and bill under its own National Provider Identifier.
4. MENTAL HEALTH PARITY Federal auditors find three New York Medicaid plans denying behavioral health prior authorizations above the state's own threshold.
5. CLAIMS INTEGRITY A money laundering guilty plea exposes a $1.42 billion equipment scheme that billed private insurers alongside Medicare.

In this issue

1. OUT-OF-NETWORK COSTS The full Fifth Circuit vacates two parts of the federal rule that sets the Qualifying Payment Amount for out-of-network claims.
2. EMPLOYER PURCHASING The National Alliance finds employers with full claim level access use 11.9 cost strategies on average against 7.9 for those without.
3. PRIOR AUTHORIZATION KFF publishes the first federally required prior authorization metrics, with insurers overturning two thirds of denied Medicare Advantage requests on appeal.
4. PBM CONTRACTING Ten pharmacy benefit managers bid on Delaware's state employee contract and none of them met all 25 of the committee's requirements.
5. PROGRAM INTEGRITY Veloxis pays more than $46 million over kickbacks to transplant providers and specialty pharmacies, including a record Sunshine Act penalty.

In this issue

1. HOSPITAL PRICING A KFF Health News investigation prices the same knee replacement at $40,000 and $16,000 in two North Carolina hospitals.
2. PAYER FINANCE HealthScape Advisors finds nearly three quarters of health plans reported operating losses in 2025.
3. DRUG PRICING A bipartisan Senate group introduces the SUSTAIN 340B Act, which would end the rebate pilot within one year.
4. PROGRAM INTEGRITY The White House puts identified federal fraud near $230 billion and opens a public tracking site.
5. COVERAGE POLICY CMS opens comment on a pathway that can finalize Medicare device coverage within 90 days of FDA authorization.

In this issue

1. HOSPITAL PAYMENT CMS finalizes a 2.3 percent FY 2027 hospital update and makes joint replacement bundles mandatory nationwide in 2028.
2. OVERSIGHT Senate Finance opens a formal record on third-party administrators, prior authorization, and employer access to claims data.
3. DRUG PRICING HRSA restarts the 340B rebate pilot with manufacturer plans due August 24 and a January 1, 2027 effective date.
4. HEALTH DATA The Senate HELP Committee advances a bill extending privacy rules to health apps, wearables, and other non-HIPAA vendors.
5. COVERAGE DISRUPTION Medicare Advantage plan exits are set to displace roughly 600,000 members, with more carriers expected to follow.

In this issue

1. PBM STRATEGY Cigna beats on Q2 earnings and says employers are asking Express Scripts for a rebate-free, fee-based PBM model.
2. PAYER EARNINGS Humana posts $694 million in Q2 net income as individual Medicare Advantage membership rises 23 percent.
3. MEDICAID MARGINS Molina raises 2026 EPS guidance but estimates managed Medicaid is underfunded by 300 basis points.
4. ERISA LITIGATION JPMorgan employees push back on dismissal of their ERISA prescription drug suit over the CVS Caremark contract.
5. MEDICAID LITIGATION A federal judge declines to block the Medicaid work rule, which takes legal effect today with merits briefing to follow.

In this issue

1. MEDICAID POLICY CMS proposes a $246 billion Medicaid provider tax phase-down
2. PROGRAM INTEGRITY HHS defers $1.07 billion over program integrity concerns
3. PHARMACY COSTS Generic drug tariffs get a 2028 start date
4. PRICE TRANSPARENCY House and Senate advance twin price transparency bills
5. MEDICARE POLICY Medicare moves to end pay for outsourced remote monitoring

In this issue

1. PBM Enforcement FTC locks in $8.5 billion in the Caremark settlement
2. Drug Pricing CMS opens a third Medicare drug price negotiation cycle
3. Legislation House Ways and Means advances seven healthcare bills
4. 340B Bipartisan SECURE 340B Act reopens the discount statute
5. Medicare Advantage Medicare Advantage quality bonuses hit $13.4 billion

In this issue

1. Medicare CMS proposes a 1.68 percent Medicare physician pay cut for 2027
2. Medicare Advantage Alignment and SCAN sue CMS over Medicare Advantage star ratings
3. Transparency HHS warns 519 hospitals over price transparency failures
4. Cost Trend PwC projects a 9 percent 2027 medical cost trend
5. PBM Reform New Jersey advances PBM reform bill A1502