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Price Transparency Rule
On September 2, 2025, the Department of Health and Human Services (HHS) published a final rule to improve real-time cost-sharing for prescription drug benefits and speed up prior authorizations. The rule modernizes electronic prescribing, allows real-time prescription benefit checks, and streamlines prior authorizations using API technology.
Who This Applies To:
Group health plans providing prescription drug coverage.
Overview:
These updates stem from the Consolidated Appropriations Act, 2021 (CAA-21), which introduced several price transparency requirements for group health plans. Patients and providers will be able to see what services or prescriptions are covered, what they cost, and how much has been spent toward deductibles and copays so far.
The rule’s requirements take effect October 1, 2025, with a transition period through 2027. Once fully implemented, patients should know their coverage approval, options, and costs before leaving their doctor’s office.
Employer Impact:
Carriers and plan administrators should begin implementing these technology standards now to stay compliant and notify plan participants once real-time prescription benefit checks are available.
Court Decisions on Gender Dysphoria Treatment
Health plans that limit or exclude coverage for gender dysphoria treatment risk running into legal issues. The law is unsettled under the ACA, Mental Health Parity rules, and Title VII civil rights protections.
Recent court decisions have varied:
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In L.B. v. Premera Blue Cross, the court ruled that excluding gender dysphoria treatment violated ACA §1557.
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In Lange v. Houston County, Georgia, earlier rulings found discrimination under Title VII, but the full Eleventh Circuit Court of Appeals later reversed those rulings, finding no violation.
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Enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) remains inconsistent.
Employer Impact:
Because the law is still evolving, employers should review any restrictions on gender dysphoria treatment with legal counsel to avoid potential investigations or lawsuits.
ACA Women’s Preventive Service Updates for 2026
The Affordable Care Act requires non-grandfathered health plans to cover certain preventive services in-network without cost-sharing. For plan years beginning in 2026, new updates affect women’s preventive services, including:
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Expanded domestic violence screening terminology and requirements.
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Additional imaging and pathology coverage following initial mammograms for women aged 40–74.
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Coverage for “patient navigation services” to help guide women through breast and cervical cancer screenings.
Employer Impact:
Self-funded employers may need to budget for additional costs and ensure carriers or TPAs can provide care navigation services.
Penalties for Non-Compliance:
Failure to comply may result in fines of $100 per person per day, plus back payment for uncovered services.
HIPAA Security Risk Assessment Tool Updated
The federal government released version 3.6 of its Security Risk Assessment (SRA) Tool, which helps employers comply with HIPAA privacy and security rules.
Who This Applies To:
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Employers with self-insured or level-funded health plans.
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Employers offering HRAs or FSAs with more than 50 participants.
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Employers with fully insured plans who receive protected health information (PHI).
Employer Impact:
Employers should designate privacy and security officials to conduct an SRA and use the updated tool to identify and mitigate data protection risks. The new version allows tracking section approvals and review dates, improving accountability.
MLR Rebates Reminder for Employers
Health insurance carriers must send out Medical Loss Ratio (MLR) rebate payments by September 30 if they did not spend enough premium dollars on claims. Employers have 90 days to determine if any portion of the rebate must be shared with plan participants.
Employer Impact:
If employees contributed to premiums, part of the rebate may be considered “plan assets” that must be distributed to participants through refunds, premium holidays, or benefit enhancements.
DOL Guidance:
MLR Rebates Guidance (PDF)
Annual Medicare Part D Notices Due by October 15
Before October 15, employers must notify all Medicare-eligible individuals (including employees, dependents, and COBRA participants) whether their prescription drug coverage is creditable or non-creditable — meaning whether it pays as well as Medicare Part D on average.
Employer Impact:
Employers should obtain creditability determinations from their carriers or TPAs. Notices can be distributed by mail, in-person, or electronically if certain rules are met.
If an employer knows coverage will no longer be creditable in the new year, that must be disclosed to allow employees to make informed enrollment decisions and avoid lifetime late enrollment penalties.
Question of the Month: What Should Employers Do When FSA Limits Are Published After Open Enrollment Starts?
The IRS often releases final FSA and commuter benefit limits late in the year, after many employers have already started open enrollment.
Options for Employers:
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Stick with current limits and reopen enrollment later when new limits are released.
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Use projected indexing to estimate next year’s limits — a reliable method based on inflation trends.
Projected 2026 Limits:
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Health FSA: $3,400 (up $100)
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FSA Carryover: $680 (20% of limit)
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Qualified Parking & Transit: $340/month (up $15)
Using projections helps avoid confusion, administrative hassle, and the need for a second enrollment window.