During the recent government shutdown, the release delayed agency guidance for employee benefits, including important healthcare transparency rules. However, transparency, particularly regarding prescription drug coverage, remains a priority of the Trump administration. Now that government operations have resumed, employers should anticipate the release of significant transparency guidance in the coming days and should understand the potential impact on their prescription drug plans.

The stopgap bill temporarily extended funding for most of the federal government through January 30, 2026. Notably, though, the bill did not include any extension of the ACA enhanced premium tax credits (PTCs), which was the central issue during the shutdown.

PCOR fees are payable by insurers and sponsors of self-insured plans (including level-funded plans, HRAs, and many point solution programs). The fees apply to retiree-only plans but do not apply to excepted benefits such as stand-alone dental and vision plans or most health FSAs.

The IRS recently issued Revenue Procedure 2025-32, providing certain cost-of-living adjustments for a wide variety of tax-related items, including health FSA contribution limits, transportation and parking benefits, qualified small employer health reimbursement arrangements (QSEHRAs), the small business tax credit, and other adjustments for tax year 2026.  

The new guidance was issued in response to President Trump’s Executive Order 14216, "Expanding Access to In Vitro Fertilization," which called for recommendations to protect in vitro fertilization (IVF) access and reduce out-of-pocket and health plan costs for IVF treatment. Specifically, the FAQs clarify the types of “excepted benefits” employers can use to provide fertility benefits.

The Affordable Care Act (ACA) enhanced premium tax credits (PTCs) are set to expire at the end of 2025, absent additional congressional action. Employers may question whether the expiration will impact their group health plans.  

Currently, ACA guidelines require group health plans to cover routine screening mammograms for women at average risk of breast cancer starting at age 40, at least biennially and as frequently as annually. Effective for plan years beginning in 2026, the coverage must also include additional imaging services (e.g., ultrasounds or MRIs) when medically indicated, and pathology services (e.g., a needle biopsy), if necessary to complete the screening process for malignancies or address findings on the initial mammography.

On August 25, 2025, a U.S. District Court denied a motion to dismiss a class action lawsuit against Kaiser Foundation Health Plan Inc. (KFHP) for its denial of coverage for prescription hearing aids, in violation of Section 1557 of the ACA. Specifically, the court found the plaintiff had standing to bring the lawsuit and adequately alleged that the plan's coverage exclusion was discrimination under the ACA.

On September 9, 2025, the Eleventh Circuit Court of Appeals held in Lange v. Houston County that a plan that did not cover gender affirming surgery did not violate Title VII of the Civil Rights Act of 1964 (Title VII). The plaintiff in the case worked for the defendant as a deputy sheriff. They are transgender and sought gender affirming surgery (as well as the drugs, services, and supplies that went along with it). However, the defendant's plan did not cover those products or services.

At issue in the case was a rule issued by the commissioner in response to the Arkansas Pharmacy Benefits Manager Licensure Act (PBMLA). The rule allowed the commissioner to impose a dispensing fee (payable to pharmacies) if pharmacy compensation is not deemed “fair and reasonable” and also included a reporting provision that required health plans to submit to the commissioner certain pharmacy compensation information. The plaintiff argued that ERISA expressly preempts any state law that may relate to an employee benefit plan.