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Twice-Weekly Briefing
Tuesday, September 29, 2026
Issue 260929-67
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
Five developments, and what each one costs you.
| 1. | BLS measured that 65 percent of private industry workers offered a medical plan took it in March. | | 2. | EBRI priced the same physician-administered drug far higher in a hospital outpatient department. | | 3. | Altarum put health care prices at 2.5 percent in August and utilization growth at 4.1 percent in July. | | 4. | GAO reviewed how Labor and the states police contraceptive coverage rules. | | 5. | The Fifth Circuit heard argument on whether a plan can sue its administrator in court. |
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| 1 · BENEFIT PARTICIPATION · September 25, 2026 |
| Medical Plans Were Available to 71 Percent of Private Industry Workers in March and 46 Percent Enrolled |
| The Bureau of Labor Statistics released Employee Benefits in the United States, March 2026 on September 25, release number USDL-26-1534. Seventy-one percent of private industry workers had access to medical care plans and 46 percent participated, a take-up rate of 65 percent. The gap holds at every establishment size. At private establishments with 1 to 49 workers, access was 55 percent, participation 34 percent and take-up 63 percent; at 500 workers or more, access reached 90 percent and participation 63 percent, and take-up still stopped at 70 percent. Among full-time private industry workers, 87 percent had access and take-up was 67 percent, against 23 percent access and 47 percent take-up for part-time workers. Dental care was available to 44 percent of private industry workers with 32 percent participating, and vision to 29 percent with 22 percent participating. |
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MOC Perspective
This release counts who could take a medical plan and who did, and take-up is the number worth borrowing. At the largest private establishments 90 percent of workers could take the plan and 63 percent did. Run those same two counts on your own census before open enrollment closes, because a low take-up rate points at your contribution tiers and your enrollment materials rather than at your claims.
What to do now
| ▪ | Calculate your own take-up rate before open enrollment closes, participants divided by eligible workers, and set it against the 65 percent BLS measured for private industry. | | ▪ | Pull participation split by full-time and part-time status, since BLS measured 47 percent take-up among part-time private industry workers against 67 percent among full-time. | | ▪ | Ask your broker for your take-up rate in each of the last 3 plan years and treat any drop of more than 3 points as an enrollment problem to fix this fall. |
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| Source: U.S. Bureau of Labor Statistics, Employee Benefits in the United States, March 2026, release USDL-26-1534 |
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| 2 · SITE OF CARE · September 24, 2026 |
| Hospital Outpatient Departments Were Paid 102 Percent More per Unit Than Physician Offices for the Same Drug |
| The Employee Benefit Research Institute published Issue Brief No. 666 on September 24, written by Paul Fronstin and M. Christopher Roebuck, using the Merative MarketScan Commercial Database for 2023 and 2024 and covering 10.9 million people in 2024. EBRI defines physician-administered outpatient drugs as injectable or infused therapies given by a health care professional and most often covered by the medical benefit. It examined 106 of them, representing 51 percent of all such claims and 77 percent of spending. Nearly 60 percent of physician-administered outpatient drugs were administered in hospital outpatient departments, 31 percent in physician offices and 9 percent in other settings, such as a patient's home. On average, hospital outpatient departments were paid 102 percent more per unit than physician offices for the same medication, while the median differential was 64 percent. If hospital outpatient departments were paid physician office rates for those 106 medications, EBRI estimates employers and workers would collectively save $9.8 billion a year, and roughly $12.7 billion across all such drugs, which it converts to about $101 per covered member annually by dividing across an estimated 126.1 million adults with employment-based health benefits. |
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MOC Perspective
Six in ten of these go to the higher-paid setting, and it is the same drug either way. This is the seam where your pharmacy data and your medical data stop talking to each other, because these drugs are most often covered by the medical benefit and the price difference lives in your hospital contract rather than your formulary. The 102 percent figure is a mean and the median is 64 percent, so your own spread depends on which facilities your members actually use.
What to do now
| ▪ | Ask your TPA for your top 20 physician-administered drugs by spend, split by place of service, for the last 12 months. | | ▪ | Price your 3 highest-spend physician-administered drugs at a hospital outpatient department and at a physician office in your largest market, and put both numbers in front of your finance lead before renewal. | | ▪ | Name site of care steerage for infused drugs as a plan design item for the next plan year and set a decision date before December 31. |
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| Source: Employee Benefit Research Institute, Issue Brief No. 666 |
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| 3 · COST TREND · September 28, 2026 |
| Hospital Prices Charged to Private Insurance Grew 4.5 Percent in August While Medicaid's Grew 0.9 Percent |
| Altarum published its September 2026 Health Sector Economic Indicators briefs on September 28, covering spending through July and prices through August. The overall Health Care Price Index stood at 2.5 percent year over year in August, equal to its July value. Underneath that single number, hospital prices grew at very different rates by payer: 4.5 percent for private insurance, 4.3 percent for Medicare and 0.9 percent for Medicaid. Physician services prices grew below 2.0 percent for all three payers, with Medicaid up 0.1 percent. National health spending, which covers all payers and the whole population rather than employer plans alone, grew 6.8 percent year over year in July, and Altarum's implicit measure of utilization growth was 4.1 percent, down slightly from 4.2 percent in June. |
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MOC Perspective
Your trend is not one number and it is not mostly price. The 6.8 percent is a national all-payer figure and it is not your self-funded plan's trend, but the hospital line for private insurance is the closest thing here to the dollar you actually pay. When utilization grows faster than price, renegotiating unit rates will not close the gap by itself, and what does move it is care management, site of care steerage and network design.
What to do now
| ▪ | Split your last 24 months of medical trend into unit price and utilization with your TPA, and ask for the split by hospital, physician and pharmacy. | | ▪ | Compare your own hospital unit cost trend against the 4.5 percent Altarum measured for private insurance in August. | | ▪ | Put 1 utilization item on the agenda for your next stewardship meeting and schedule that meeting before October 31. |
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| Source: Altarum, Health Sector Economic Indicators, September 2026 |
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| 4 · PREVENTIVE COVERAGE · September 24, 2026 |
| Labor Found Contraceptive Coverage Violations in Three Investigations Over Six Years, One Involving a PBM |
| The Government Accountability Office published Private Health Insurance: Federal and State Oversight of Contraceptive Coverage Requirements, GAO-26-108446, on September 24. The Department of Labor, the federal regulator of ERISA group health plans, identified noncompliance with federal contraceptive coverage requirements in three investigations it conducted in the last six years, according to DOL officials. In one, DOL found that a pharmacy benefit manager required enrollees to try other types of contraception before covering the medically necessary, preferred method at no cost sharing. CMS identified noncompliance in three out of five market conduct examinations conducted in the last six years. GAO selected six states to review, it says, to capture variation in rurality and state laws, among other criteria. |
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MOC Perspective
The violation GAO describes is a step therapy rule sitting inside a pharmacy benefit. Members had to fail other methods first before the plan would cover the one their clinician chose without cost sharing. That rule was not written by your benefits committee and it may not appear anywhere in your medical plan document. Three DOL findings in six years tells you how much of this a regulator catches, not how much of it is out there.
What to do now
| ▪ | Ask your PBM in writing whether any contraceptive on your preventive list carries step therapy or prior authorization, and set a reply date of October 31. | | ▪ | Pull your plan's exceptions process for preventive contraceptive coverage and confirm in 1 page that a member can reach it without paying first. | | ▪ | Name the party responsible for preventive services compliance in your administrative services and PBM contracts, and file the 2 clause numbers with your fiduciary records. |
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| Source: U.S. Government Accountability Office, GAO-26-108446 |
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| 5 · PLAN CONTRACTS · September 24, 2026 |
| The Fifth Circuit Heard Argument in a Self-Funded Plan's Suit Against Its Own Claims Administrator |
| The U.S. Court of Appeals for the Fifth Circuit heard oral argument on September 24 in Aramark Services, Incorporated Group Health Plan v. Aetna Life Insurance Company, No. 24-40323, on appeal from No. 2:23-CV-446 in the Eastern District of Texas. Aetna is the Defendant-Appellant and the Aramark plaintiffs are the Appellees. The panel opinion of December 18, 2025 records Aramark's allegation that since 2017 Aetna “has paid millions of dollars of provider claims that should not have been paid, retained millions of dollars in undisclosed fees, and engaged in claims-processing related misconduct to Aramark's detriment.” That opinion also framed the two threshold questions: “whether the court or the arbitrator will decide arbitrability, and whether the Plaintiffs seek equitable relief.” On April 28, 2026 the court ordered that the cause “shall be reheard by the court en banc” and that, under Fifth Circuit Rule 41.3, “the panel opinion in this case dated December 18, 2025, is VACATED.” Counsel for the appellant, the appellee and an amicus each argued on September 24, and no decision has issued. |
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MOC Perspective
A self-funded plan is suing the administrator that paid its claims, and the first question is not whether the plan is right. It is whether the plan is allowed in court at all, because the vacated panel opinion describes an arbitration clause at Section 15 of the parties' Master Services Agreement calling for binding arbitration in Hartford under the American Arbitration Association. You signed a clause like that one. Nothing is settled here, the panel opinion is vacated and no new opinion has issued, so the thing you control this week is knowing exactly what your own agreement says.
What to do now
| ▪ | Read the dispute resolution section of your administrative services agreement this week and write down the 3 things it names: the forum, the seat and the administrator. | | ▪ | Ask your counsel whether that clause reaches ERISA fiduciary claims or only contract claims, and get the answer in writing by October 15. | | ▪ | List the 3 plan asset questions you would most want answered in discovery, then check whether the audit rights in the same agreement already reach them. |
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| Source: U.S. Court of Appeals for the Fifth Circuit, No. 24-40323 |
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The Bottom Line
Three of these five stories land on paper you already have, and a fourth takes one letter. Your census carries your take-up rate. Your claims file shows where physician-administered drugs were given and what each setting was paid. Your PBM can tell you in writing whether any contraceptive on your preventive list carries a step therapy rule, and your administrative services agreement says where a fight with your administrator gets decided. None of that needs a purchase or a new plan year, and the longer those documents go unread, the more they decide on your behalf.
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Jude Odu
Founder and Principal, Model Optimal Care
Author of Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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