- Regulation: 2026 Consolidated Appropriations Act
- Blog: Consolidated Appropriations Act of 2026: The New Landscape of PBM Fiduciary Oversight
- Blog: ERISA Amended to Expand Oversight of Entities That Provide PBM Services | Miller & Chevalier
- Fact Sheet: Proposed Pharmacy Benefit Manager Fee Disclosure Rule | U.S. Department of Labor
- Fact Sheet: TrumpRx.gov to Bring Lower Drug Prices to American Patients | The White House
- IRS: FAQs about the Premium Tax Credit
- IRS: Form 5500 Series | U.S. Department of Labor
- HHS: Model Notices of Privacy Practices | HHS.gov
- Blog: Updated HIPAA & Part 2 notices released, OCR enforcement commences | Nixon Peabody LLP
- Blog: ICHRA push reinvigorates employer health market in Connecticut | BenefitsPro
- Blog: Trump accounts: The basics | McAfee & Taft
- Blog: Why Employers Should Form a Welfare Plan Fiduciary Committee | Insights & Events | Bradley
- Blog: Fertility benefits by state: what insurance covers IVF & where coverage is mandated | Nava
- Blog: GLP-1s & Employer Plans: Cost Pressure, Coverage Strategies, & Managing Risk | Akerman LLP
- Blog: Proposed Transparency Rule for Self-Insured Group Health Plans | Insights | Ropes & Gray LLP
Compliance Reminders
- March 1, 2026 – Electronically submit via CMS the Medicare Part D Creditable Coverage Form
- March 1, 2026 – If a breach of PHI occurred in 2025, review whether reporting to HHS is required
- March 2, 2026 – File Forms 1094/1095 with IRS (if paper filing) & furnish to employees (if providing paper statements) & post a clear notice to persons that they can request a copy of their form
- March 2, 2026 – File Form M-1 with DOL if a Multiple Employer Welfare Arrangement (MEWA)
- March 31, 2026 – File Forms 1094/1095 with the IRS (if filing electronically)
- June 1, 2026 – File annual RxDC & Healthcare Spending Report via CMS
The 411: Consolidated Appropriations Act of 2026
February 3rd, 2026, marked the second signing of a consolidated appropriations act. This time, Pharmacy Benefits Managers (PBMs) and Third-Party Administrators (TPAs) to employer-sponsored group health plans are the target of strengthened oversight. The CAA of 2026 includes regulations on requirements of contracts between health plans or insurers and PMBs beginning on or after August 3, 2028. Provisions impacting health plans:
1. PBM Oversight – both fully insured & self-funded plan contracts with such providers must include specific disclosures on drug costs & compensation from all sources (rebates, fees, etc.).
a. Disclosure & timing obligations: Applicable Entities (AEs) must disclose all direct and indirect compensation (AEs include affiliates of plans, insurers, and PBMs). Two tiers of disclosures exist depending on employer and plan size or status. Penalties apply for failures. Review details beginning on page 498.
2. 100% Rebate Pass-Through Mandate – requires PBMs that receive any remuneration from drug manufacturers to pass 100% through to plans & issuers. Plans & issuers may pass through to participants.
“Rebates must be remitted to plans or insurers quarterly. Plans may also audit remittances. Bona fide service fees are allowed if transparent and quantifiable. Fiduciary liability protection is provided for responsible plan fiduciaries that were unaware of a PBM’s remittance failure and take specified actions.”
Source: Thompson Reuters, 2026
2027 ACA Cost-Sharing Limitations
The Department of Health & Human Services (HHS) announced 2027 maximum annual limitations on cost-sharing for the 2027 benefit plan year for non-grandfathered plans subject to the ACA.
• The maximum annual limit on cost-sharing for 2027 will increase to $12,000 for self-only coverage; and $24,000 for other than self-only coverage.
• Cost-sharing includes deductibles, coinsurance, copayments, and other expenses that are qualified medical expenses respecting essential health benefits covered under the plan.
Civil Monetary Penalties Increased Jan. 28, 2026
HHS adjusted monetary penalties for violations of statutes under such laws as HIPAA, Medicare Secondary Payer Rules, and ERISA. Common penalties affecting employer-sponsored welfare plans are listed below. Review regulations for a full list.
1. HIPAA Administrative Simplification – standards for privacy, security, breach notification & electronic healthcare transactions.
a. Tier 1—Lack of Knowledge. The minimum penalty is $145; the maximum penalty is $73,011; and the calendar-year cap is $2,190,294 (all tiers).
b. Tier 2—Reasonable Cause and Not Willful Neglect. The minimum penalty is $1,461; the maximum penalty is $73,011
c. Tier 3—Willful Neglect, Corrected Within 30 Days. The minimum penalty is $14,602; the maximum penalty is $73,011
d. Tier 4—Willful Neglect, Not Corrected Within 30 Days. The minimum penalty is $73,011f; the maximum penalty is $2,190,294
2. Medicare Secondary Payer
a. Offering incentives to Medicare-eligible individuals not to enroll in a plan that would otherwise be primary: $11,823
b. Failure of responsible reporting entities to provide information identifying situations where the group health plan is primary: $1,512
3. Summary of Benefits and Coverage (SBC) – the SBC must be provided to participants and beneficiaries before enrollment or re-enrollment in a group health plan.
a. The penalty for a health insurer’s or non-federal governmental health plan’s willful failure to provide an SBC is $1,443 for each failure.