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.

A recently filed putative class action lawsuit, Barbich et al v. Northwestern University et al, raises concerns that a new wave of ERISA fiduciary breach claims may be on the horizon. In Barbich, the plaintiffs allege that Northwestern University, as the group health plan sponsor, breached its fiduciary duties by failing to prudently select and monitor their medical plan options and by not disclosing material plan information to participants...

On August 26, 2025, the Fifth Circuit Court of Appeals remanded Braidwood Management Inc. v. Becerra, Inc. back to the district court for further proceedings. The Fifth Circuit made this move in response to the recent Supreme Court ruling in this case.

On August 12, 2025, in Erban v. Tufts Medical Center Physicians Organization, et al., a Massachusetts district court found that the fiduciaries of an ERISA group life insurance plan breached their fiduciary duties to provide accurate and complete information to a terminally ill participant and his spouse regarding coverage continuation options. The ruling provides helpful insights for ERISA plan fiduciaries regarding their disclosure obligations to participants and beneficiaries, particularly those impacted by serious illnesses or impairments.

On August 13, 2025, the District Court of the Eastern District of Pennsylvania vacated federal rules that provided exemptions for contraceptive coverage requirements imposed by the ACA. The court determined that those rules violated the federal Administrative Procedure Act (APA).

On July 28, 2025, in Express Scripts, Inc. et al v. Richmond et al, the United States District Court for the Eastern District of Arkansas granted the plaintiffs’ motion for a preliminary injunction to prevent enforcement of Arkansas Act 624, which restricts pharmacy benefit managers (PBMs) from owning and operating pharmacies in the state. The court agreed with the...