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Twice-Weekly Briefing
Friday, October 2, 2026
Issue 261002-68
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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. | Trump account rules took effect September 30, and employers may now contribute | | 2. | Federal 2027 health premiums are set, and the enrollee share rises faster than the total | | 3. | Elevance will check hospital bills against hospital addresses before paying the hospital rate | | 4. | Two of the three largest PBMs have posted 2027 exclusions, and the third's page shows nothing past 2026 | | 5. | Prior authorization burden rose while two other physician burdens fell |
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| 1 · Employer Contributions · September 30, 2026 |
| Employers Can Now Fund a Trump Account for a Worker or a Worker's Dependent, Up to $2,500 Tax Free |
| Treasury and the IRS published temporary regulations on Trump accounts on September 30, 2026, and the rules took effect the same day. Contributions during the growth period are generally subject to an annual limit of $5,000, adjusted for inflation for taxable years after 2027. "Employers may contribute to the Trump account of an employee or an employee's dependent", and under section 128 that contribution is excluded from the employee's income up to $2,500 a year, which the regulations state counts toward the $5,000 limit rather than sitting on top of it. A separate $1,000 pilot contribution comes from Treasury, not from you, and reaches a U.S. citizen born in 2025, 2026, 2027 or 2028 who has been issued a Social Security number. A companion proposed rule published the same day, document 2026-20027, takes comments until November 30, 2026 under reference CC-00226466-26. |
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MOC Perspective
The practical deadline is your own: decide before your 2027 enrollment materials go to print. Nothing in the rules makes you fund a contribution, and the amount is real money if a lot of your employees have children under 18. The part that will cost you is the exclusion: a section 128 contribution is excluded from the employee's income, so payroll has to code it as an excludable benefit rather than as wages, and the companion proposed rule would attach nondiscrimination rules to it, which is one more reason to read it before November 30. Employees will not claim an account nobody told them about.
What to do now
| ▪ | Decide before your 2027 enrollment materials print whether to fund a section 128 contribution, and at what amount up to $2,500. | | ▪ | Confirm with payroll before January 1 that a section 128 contribution runs as an excludable benefit and not as taxable wages. | | ▪ | File a comment by November 30, 2026 under reference CC-00226466-26 if the auto-enrollment mechanics reach your population. |
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| Source: Federal Register, Internal Revenue Service and Treasury Department, TD 10056, RIN 1545-BS27, document 2026-20026 |
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| 2 · Renewal Benchmark · September 30, 2026 |
| Federal Employees Health Benefits Premiums Rise 9.3 Percent for 2027 and the Enrollee Share Rises Faster |
| The Office of Personnel Management announced the 2026 Federal Benefits Open Season on September 30, 2026 and published the rates that go with it. Federal Employees Health Benefits premiums rise an average of 9.3 percent for plan year 2027. The enrollee share rises 10.9 percent and the government share 8.6 percent, so the number a federal worker sees on a pay stub moves further than the headline does. The Postal Service Health Benefits program is a separate program and lands lower, at 6.7 percent overall with an 8.2 percent enrollee share. OPM names its own cost drivers: "Rising prices and utilization across inpatient, physician, outpatient, and surgical services", "Continued growth in behavioral and mental health care", and "Higher prescription drug spending", particularly on GLP-1s, specialty drugs and other high-cost therapies. Open season runs November 9 through December 14, 2026. |
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MOC Perspective
These are rates already set for a book of business that opens enrollment on November 9, not a forecast. That makes them the cleanest public comparator you will get before you sign your own 2027 renewal. The useful number is not the headline average, it is the split: a federal employer held its own share to 8.6 percent and passed 10.9 percent to the enrollee. Ask whether your renewal divides the same way, and whether your carrier will attribute your trend to the same three categories OPM named.
What to do now
| ▪ | Put the 9.3 percent federal average beside your own 2027 renewal increase before you sign it. | | ▪ | Ask your carrier or TPA by November 9 to split your 2027 trend across the three categories OPM named. | | ▪ | Model what a 10.9 percent employee contribution increase does to your enrollment mix before open enrollment opens. |
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| Source: U.S. Office of Personnel Management, news release of September 30, 2026, and 2026 Federal Benefits Open Season Highlights for Plan Year 2027 |
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| 3 · Site of Service · September 29, 2026 |
| Elevance Will Make Hospitals Say Where Care Happened Before It Pays the Hospital Rate |
| Elevance Health announced new hospital billing policies on September 29, 2026, and "The policies will apply across Elevance Health's commercial, Medicare Advantage and Medicaid businesses." Hospitals will have to identify the physical location where care was provided, and Elevance will check billing information against hospital addresses to confirm where care took place. Certain off-campus hospital services will be paid at the appropriate off-campus rate, and higher hospital billing for certain lab tests performed somewhere else will be blocked. Elevance plans to implement individual policies throughout 2026 and 2027, with no policy-by-policy date published, and notes that new federal requirements for off-campus hospitals are scheduled to take effect in 2028. The release puts U.S. hospital care at about $1.6 trillion in 2024, 31 percent of all U.S. health care spending, after growth of 10.6 percent in 2023 and 8.9 percent in 2024. |
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MOC Perspective
Read the scope line twice. Elevance says commercial, and it does not say self-funded or administrative services only, so you cannot assume these edits reach your plan on any particular date. The release carries no commercial savings estimate at all, and its two dollar figures are Blue Cross Blue Shield Association estimates from Medicare: $2.7 billion more paid by Medicare and $411 million more paid by patients out of pocket over three years. The off-campus rate and the reference lab edits are the two that move money on a self-funded book, and whether they apply to you is a question for your account team rather than for a press release. Note the gap between the two dates in the release: Elevance is editing in 2026 and 2027 against a federal requirement it says takes effect in 2028, so this is a carrier policy choice ahead of a rule and not compliance with one. That is the difference between a change you can ask to be scoped to your plan and a change you cannot.
What to do now
| ▪ | Ask your Elevance or Anthem account team by November 30 which of the new billing policies reach your plan, and when each one starts. | | ▪ | Pull your 12 highest-volume outpatient procedure codes and count how many were billed from an off-campus hospital location in 2026. | | ▪ | Name the reference lab your plan uses and confirm in writing before January 1 that its claims are not priced at the hospital outpatient rate. |
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| Source: Elevance Health newsroom |
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| 4 · Pharmacy Formulary · Effective January 1, 2027 |
| Express Scripts Excludes Zepbound Vials and KwikPens for 2027 While Keeping Zepbound Pens Covered |
| Express Scripts has posted its 2027 National Preferred Formulary Exclusions, and the companion 2027 National Preferred Formulary states of itself that "THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2027, THROUGH DECEMBER 31, 2027." Neither document carries a publication date, and the only date on the exclusions sheet is the control string CRP1584203A 204612 NP Excl (08/01/2026) in its footer. The sheet lists ZEPBOUND KWIKPENS and ZEPBOUND VIALS as excluded and names ZEPBOUND PENS among the preferred alternatives, so the drug stays covered and two of its presentations do not. The named alternatives for those two are liraglutide, FOUNDAYO, WEGOVY HD, WEGOVY PENS, WEGOVY TABLETS and ZEPBOUND PENS, which is six covered options, one of them the same drug in a different device. KISUNLA, LEQEMBI and LEQEMBI IQLIK carry the line "Coverage may be approved for the treatment of Alzheimer's under certain conditions." Optum Rx has posted nine documents for January 1, 2027 with no publication date at all, and its 2027 Premium Standard Formulary puts the same three products at Tier E, excluded, with a specialty flag. CVS Caremark's formulary page carries nothing for 2027 and references no year later than 2026. |
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MOC Perspective
There is no announcement attached to any of these documents, and that does not make them less binding. They take effect January 1, and moving a member off an excluded presentation of a drug you still cover means a new prescription, which is work that belongs in open enrollment rather than in January. The Alzheimer's entries are where this crosses your benefits: two PBMs have arrived at the same place by two different routes, one through a conditional approval line and one through a tier plus a specialty flag, and neither publishes the condition itself. Note what is absent from the Express Scripts and Optum documents: no exclusion count, no savings figure, no publication date.
What to do now
| ▪ | Run the 2027 exclusions sheet against your top 50 drugs by spend before open enrollment closes. | | ▪ | List every member filling Zepbound vials or KwikPens and move them to a covered presentation before January 1. | | ▪ | Ask your PBM in writing for the Alzheimer's conditional approval criteria, with a reply date of November 30. |
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| Source: Express Scripts, 2027 National Preferred Formulary Exclusions |
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| 5 · Prior Authorization · September 30, 2026 |
| Prior Authorization Burden Rose to 58 Percent of Surveyed Family Physicians While Two Other Burdens Fell |
| Analysts at ONC, the Office of the National Coordinator for Health Information Technology, published findings on September 30, 2026 from a study of more than 8,400 family physicians. Substantial prior authorization burden "moved in the opposite direction, remaining persistently high and increasing from 54% in 2024 to 58% in 2026." Over the same two years, substantial burden tracking down external health information fell from 43 percent to 38 percent, and substantial pajama time, defined as three or more hours a day, fell from 41 percent to 34 percent. The share carrying all three burdens at once went from 15 percent in 2024 to 12.2 percent in 2026, which the authors extrapolate nationally to approximately 3,000 fewer family physicians carrying all three. Prior authorization is the one that moved the wrong way. |
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MOC Perspective
This measures what utilization management costs the physicians who have to comply with it, and prior authorization got worse over the same two years in which two information-handling burdens got better. The study does not break out payer or plan type, so it is not a measurement of your plan. It is the question to put to your TPA: if this burden is rising across the board while your carrier markets a reduction, one of those two things is not true on your book. The answer sits in your own 2026 numbers and not in a national average.
What to do now
| ▪ | Request your plan's 2026 prior authorization volume as a share of medical claims, measured against 2025. | | ▪ | Ask for your plan's median prior authorization turnaround and approval rate for the 12 months ending September 30. | | ▪ | Name every service category your carrier removed from your prior authorization list in 2026, and the date each came off. |
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| Source: Office of the National Coordinator for Health Information Technology, healthit.gov Health IT Buzz, September 30, 2026 |
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The Bottom Line
Four of these five stories end with a question for your carrier, your TPA or your PBM: which of the new hospital billing policies reach your plan and when, which of your members fill an excluded presentation, how your 2027 trend divides between you and your employees, and what your own prior authorization numbers did this year. The Trump account decision is the one that is entirely yours. You can set a section 128 contribution amount, or decide against one, before your enrollment materials print, and nobody has to give you permission to do it.
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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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