Key Health Benefits Policy Updates for Employer Plans in 2025
Recent legislative and policy changes are reshaping the U.S. employer-sponsored health benefits landscape, affecting plan sponsors, insurers, third-party administrators (TPAs), and employees. Notably, starting January 1, 2025, high-deductible health plans (HDHPs) will be permitted to cover telehealth and remote care services without disqualifying participants from making health savings account (HSA) contributions, enhancing the flexibility of telemedicine access within these plans.
Federal regulations related to Section 1557 are evolving, potentially altering nondiscrimination protections around gender-affirming care. With states adopting disparate policies—some mandating coverage while others impose restrictions—employers and plan administrators must conduct thorough reviews of coverage provisions and understand where employees are geographically located to ensure compliance and meet employee needs.
New state-level regulations are targeting pharmacy benefit managers (PBMs) on drug pricing and rebate transparency, creating complex compliance challenges as these may intersect with ERISA preemption rules. Employers and plan sponsors are advised to seek legal guidance to navigate state disclosure demands and avoid conflicts. Additionally, the Affordable Care Act’s preventive care coverage mandate remains but faces potential legal challenges, particularly concerning contraception and PrEP services, necessitating ongoing monitoring to preempt plan disruptions.
Plan design modifications include the 2026 update allowing direct primary care arrangement participants to make HSA contributions and use HSA funds for certain direct care fees. Employer interest is expanding in travel benefit programs to enable access to services restricted in certain states, such as gender-affirming and reproductive care, which introduces legal complexities amid the evolving state regulatory environment.
Economic pressures also influence the benefits sphere. Changes in Medicaid eligibility and tax credits could increase uninsured populations, potentially shifting enrollment to employer plans and escalating costs. Concurrently, hospitals facing revenue shortfalls may raise prices for private plan services, impacting negotiated rates. Rising enforcement and litigation risks underscore the need for strategic planning.
Plan sponsors are encouraged to adopt proactive strategies including compliance audits, adaptable benefit designs, and thorough legal consultation to effectively manage these dynamic regulatory and market conditions. Such measures can help mitigate risk and align benefits with both regulatory requirements and employee expectations.