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"Umbrella
Uncategorized

Are Your Benefits Enough to See Employees Through a Crisis?

by Inoventive Solutions
March 3, 2026

Middle-class families — those with incomes of between roughly $50,000 and $180,000 per year (depending on where they live) — are becoming increasingly reliant on workplace benefits to ensure their financial well-being in case of a disability or critical illness.

Simple health insurance is insufficient to carry the load. The loss of a breadwinner’s or caregiver’s financial contribution through death or disability is often devastating.

A recent survey by benefits provider Guardian indicates that families in this category are struggling when it comes to achieving their financial goals. Of those workers surveyed only half believe they would be able to manage if the household lost an income due to death or illness.

Caught in the middle

Families with incomes significantly above $100,000 per year are generally able to create at least some financial cushion against the possibility of death or disability. They also receive a good deal of advice from financial advisors, accountants and insurance agents in managing their financial affairs. 

Working class families – those with incomes below about $50,000 – are often able to access various parts of the social safety net in times of crisis.

The “middle market,” in contrast, must make do without the advantages of the more affluent, with fewer privately owned insurance products and services, and without the same access to the social safety net afforded to working-class families.

Workplace benefits are critical 

According to Guardian’s researchers, the middle-market population is overwhelmingly reliant on the quality and breadth of the benefits they receive at work, over and above cash compensation.

Over 80% of middle-market respondents report that they got their health insurance, disability insurance and retirement plan all through their employer.

Meanwhile, six in 10 have no life insurance in place outside of the workplace. This means that the solid majority of working families are relying entirely on workplace benefits to see them through the death of a family breadwinner.

And in the event of disability ending a breadwinner’s income, the situation is even more dire: Only 7% of the middle market owns any kind of disability insurance protection, outside of what they can access via their employer.

Are life insurance benefits adequate? 

For young families, the primary role of life insurance is to replace the income of a deceased breadwinner. But many employers cap life insurance benefits at $50,000 — the maximum figure that allows employers to deduct premiums as a workplace benefit under IRC 7702.

The actual need for many of these families is several hundred thousand to a million dollars, and occasionally more. That’s what it takes to replace the income of a worker who earns $50,000 to $100,000 per year until the children are out of college and a surviving spouse is taken care of.

The cap on group life insurance is often not enough to help a family who loses their breadwinner, and the coverage should be considered a stopgap for a more robust life insurance policy purchased in the private market. 

What employers can do

One solution is to offer voluntary benefits to workers. These include a menu of benefits, such as:

  • Group life insurance
  • Group disability insurance
  • Long-term care insurance
  • Critical illness coverage

Often, many of these benefits can be offered at little or no cost to the employer. 

Premium costs are simply deducted from the worker’s wages and forwarded to the insurance company via payroll deduction. In this way, workers can purchase much more coverage and provide protection for their families – and it doesn’t cost the employer a dime.

In some instances, it can even save on payroll taxes.

To learn more, call us. 

"holding
Uncategorized

More Employers Offer Caregiver Leave as Need Mounts

by Inoventive Solutions
February 24, 2026

A new survey found that many employers plan to add or expand caregiver leave as they contend with workforce burnout, changing family dynamics and competition for talent.

According to WTW’s “2025 Absence, Disability and Medical Leave Survey,” caregiver leave is expected to see the fastest growth of any leave benefit over the next two years, despite only a handful of states requiring it by law. The shift comes as caregiving demands intensify across a multigenerational workforce. Many employees juggle work while caring for aging parents, children or other dependents, often with limited financial or workplace support.

Employers are finding that caregiver leave can help reduce stress and burnout, improve morale and productivity and support retention in a tight labor market where replacing workers is increasingly expensive.

What the WTW survey found

  • 73% of employers plan to enhance leave programs over the next two years.
  • 39% of employers expect to offer caregiver leave within two years, up from 22%.
  • Employers cite improving employee experience (67%) and strengthening attraction and retention (60%) as the top reasons for expanding leave benefits.
  • 49% of employers identify leave program administration as their biggest challenge, followed by system integration and workforce coverage.

The importance of caregiver leave

Caregiver leave addresses a growing gap for a workforce that increasingly spans multiple generations. Nearly one quarter of U.S. adults are part of the so-called “sandwich generation,” caring for both children and aging parents, according to another report. These employees often provide about 20 hours of unpaid care per week and may spend $10,000 to $11,300 a year out of pocket to support family members.

Although caregiver leave may qualify under the Family and Medical Leave Act (FMLA), it is typically unpaid unless employers offer wage replacement. That financial strain can increase stress and burnout, pushing some caregivers to reduce their hours, change jobs or leave the workforce entirely.

From a business standpoint, caregiver leave can help mitigate turnover risk. Replacing an employee can cost about 30% of annual pay. While caregiver leave will not eliminate turnover, it can lower the risk that employees leave because of caregiving responsibilities.

How employers can implement caregiver leave

Employers considering caregiver leave often start by integrating it into their existing leave or paid time off structures.

Common approaches include offering a defined number of paid leave days per year, allowing caregiving use of banked personal time off or layering caregiver leave on top of state paid family leave programs.

Best practices include:

  • Defining caregiving broadly to cover children, parents, spouses, domestic partners and other dependents.
  • Coordinating caregiver leave with FMLA and state programs to avoid duplication and ensure compliance.
  • Setting clear eligibility and documentation standards while keeping the process simple for employees.
  • Training managers to handle workload planning and employee conversations.

Overcoming administrative and operational challenges

Administration remains one of the biggest barriers to expanding caregiver leave. Challenges include coordinating multiple leave programs, maintaining multistate compliance and managing staffing as leave usage increases.

To address these issues, many employers are:

  • Outsourcing leave administration to specialized vendors.
  • Standardizing policies and systems across locations.
  • Using technology to support routine leave management.
  • Monitoring utilization to ensure caregiver leave is accessible and free of stigma.

The takeaway

As caregiving responsibilities continue to affect a growing share of the workforce, caregiver leave is emerging as a practical, targeted benefit that supports employees while helping employers attract and retain talent in a competitive labor market.

"Shot
Uncategorized

Voluntary Benefits Lawsuits Add Fiduciary Concerns for Employers

by Inoventive Solutions
February 3, 2026

Plaintiff’s lawyers are breaking new ground by suing employers for allegedly failing in their fiduciary duties to manage their voluntary benefit plans, including dental, vision, accident insurance, critical illness, cancer and hospital indemnity benefits.

These class action lawsuits typically allege that employers exercise sufficient control over these plans to trigger fiduciary duties under the Employee Retirement Income Security Act (ERISA) and that those duties were breached. Once ERISA applies, employers can face claims tied not just to plan design, but to the prudence of benefit selection and monitoring.

If these lawsuits gain traction, they may open a new category of potential liability tied to benefit offerings that many employers have historically overlooked.

At the center of the litigation is the claim that certain voluntary benefit arrangements are not exempt from ERISA, either because they fail to meet the voluntary plan safe harbor or because employers exercise sufficient control to trigger fiduciary duties.

Five areas drawing scrutiny

Four recent class action lawsuits filed against large employers include similar allegations that the employers and their benefits brokers breached ERISA fiduciary duties by allowing excessive commissions, failing to monitor insurers and brokers and engaging in conflicted arrangements within employer-sponsored voluntary benefits programs.

Each of these companies was sued by an employees’ union benefit or welfare plan:

  • United Airlines
  • Laboratory Corporation of America
  • Community Health Systems
  • Allied Universal

Key areas of alleged exposure include:

1. Benefits selection processes — Employers are being accused of failing to run competitive requests for proposals, benchmark offerings or document why certain carriers or products were chosen. A casual selection process that keeps the same plan each year can be portrayed as imprudent once fiduciary standards apply.

2.  Contracts — Agreements with insurers, brokers and enrollment vendors are under the microscope. Vague terms, unclear delegation of responsibilities or contracts that fail to spell out fiduciary status can make it harder for employers to defend their role as plan sponsors.

3. Broker and vendor compensation provisions — Embedded commissions, overrides and incentive payments are a central theme in the lawsuits. Plaintiffs argue that employers failed to monitor compensation levels or allowed conflicted arrangements that inflated employee premiums.

4. Premium levels — Even when employees pay the full cost, plaintiffs contend that employers must ensure premiums are reasonable relative to the benefits provided. A lack of benchmarking can be framed as a breach of the duty of prudence.

5. Insurance product loss ratios — Loss ratios are being used as a proxy for value. Low ratios may be cited as evidence that plans were overpriced or structured to favor intermediaries rather than participants.

Steps employers can take

While none of these cases has been decided on the merits, they send the message that voluntary benefits are no longer viewed as litigation-proof. Employers and HR leaders may want to consider:

  • Confirming whether each voluntary benefit arrangement is intended to be ERISA-covered or exempt — and documenting that determination.
  • Reviewing contracts to clarify fiduciary roles, responsibilities and delegation.
  • Increasing transparency around broker and vendor compensation, including commissions and incentives.
  • Benchmarking premiums and insurer loss ratios against the broader market.
  • Documenting benefit selection decisions and the rationale behind them.
  • Strengthening employee decision support and education to demonstrate a focus on participant outcomes.

Voluntary benefits may remain optional for employees, but the lawsuits suggest fiduciary oversight is becoming less optional for employers. Employers that pay closer attention now to ensure compliance with any applicable fiduciary duties can reduce their risk of becoming the next test case.

"GLP-1
Uncategorized

Employers Experiment with Direct-to-Consumer Access for GLP-1s

by Inoventive Solutions
January 27, 2026

Employers grappling with the cost and complexity of GLP-1 drugs are increasingly testing a workaround: steering certain employees to direct-to-consumer (DTC) arrangements that operate outside the company’s health plan.

The shift reflects a growing tension for benefits executives: how to manage soaring GLP-1 demand while preserving affordability, plan sustainability and clinical oversight.

How direct-to-consumer works

Under a DTC model, employees purchase GLP-1 drugs outside the pharmacy benefit on a manufacturer or designated website. Deductibles, out-of-pocket maximums, prior authorization and PBM utilization management requirements do not apply.

While this removes plan-level clinical guardrails, it can materially lower employees’ monthly costs. In many cases, cash-pay prices offered by manufacturers or online platforms are lower than what employees would pay through insurance even after discounts and coinsurance.

Instead of covering GLP-1s as a plan benefit, some employers provide fixed monthly stipends — often $100 to $200 — to offset the cost of direct purchases. This allows employers to cap financial exposure while still offering employees access to treatment.

Drug manufacturers are accelerating this shift. Eli Lilly and Novo Nordisk have expanded DTC programs that allow patients to purchase GLP-1 drugs without using insurance, with monthly cash prices below historical list prices.

Beyond consumer programs, both Lilly and Novo Nordisk are piloting direct-to-employer (DTE) models that bypass traditional PBM structures. In these arrangements, self-insured employers negotiate pricing directly with manufacturers, while third-party administrators handle eligibility screening, prescribing coordination and fulfillment. The goal is to move pricing closer to net cost and reduce employee cost-sharing.

According to the Peterson Health Technology Institute, some employers are evaluating DTC and DTE arrangements because these may offer lower prices than those through traditional pharmacy benefits. They also provide employers with more predictable spending. 

However, benefits leaders should view these arrangements as complementary tools rather than replacements for a structured GLP-1 strategy.

Pros and cons

Pros:

  • Lower out-of-pocket costs for certain employees.
  • Second-chance access for employees who do not qualify under plan rules.
  • Predictable employer cost exposure when using fixed stipends or subsidies.
  • DTC models typically bypass prior authorization and PBM requirements, reducing friction and administrative delays for employees.

Cons:

  • Loss of clinical oversight and utilization controls. Off-benefit purchases bypass prior authorization, step therapy and ongoing clinical management built into the plan.
  • Employers lose access to claims data needed to track adherence, safety, effectiveness and long-term cost trends.
  • Employees may underestimate their total financial exposure, particularly if they later transition back to plan-based coverage.
  • Cash-pay prices can make plan coverage appear inefficient or overpriced, even when the pricing structures are not directly comparable.
  • Manufacturer DTC pricing reflects market strategy, not negotiated benefit contracts, and can change or be withdrawn with little notice.
  • Once established for GLP-1s, employees may expect similar pathways for other high-cost medications.

What employers can do

For many employers, the most pragmatic use of DTC access is as a secondary pathway. Employees who do not meet plan eligibility criteria can still pursue treatment without forcing employers to broaden coverage in ways that may be financially unsustainable.

As manufacturers continue to refine pricing strategies and employer pilots mature, benefits executives may find that selective use of DTC models offers flexibility in an increasingly complex GLP-1 landscape — provided these pathways are integrated thoughtfully into an overall benefits strategy rather than used as a blunt cost-cutting tool.

"stethoscope
Uncategorized

‘Stealth’ Health Plan Cost Drivers Employers Can’t Ignore

by Inoventive Solutions
January 13, 2026

As employers face rapidly rising health insurance costs for their employees, industry pundits are increasingly urging benefit leaders to confront “stealth” cost drivers that quietly inflate spending year after year.

While headline issues like premium increases draw the most attention, some of the most meaningful opportunities to control costs lie in areas that are often underinvested or poorly integrated into benefit strategies.

Addiction support services

Behavioral health, and particularly substance use disorders, remains one of the most expensive and least efficiently managed areas of employer-sponsored health care.

Untreated mental health and addiction issues contribute to higher medical claims, absenteeism and lost productivity. According to the Center for Prevention and Health Services, untreated mental health concerns can cost a single organization tens of thousands of dollars annually and amount to more than $100 billion nationwide.

Despite those figures, addiction and recovery services have historically received less attention than other wellness initiatives. Inpatient treatment models can be disruptive for employees and expensive for employers, while high relapse rates have made some organizations hesitant to invest more heavily in this space.

Employer actions: As a result, employers are increasingly looking at more structured, accountable recovery programs that focus on ongoing support, medication-assisted treatment and measurable outcomes.

Improving access to specialty care

Employees may technically have coverage, but long wait times for specialists can delay treatment and worsen underlying conditions. Nationally, more than 100 million specialty referrals are issued each year, yet patients in many metropolitan areas wait more than a month to see specialists such as gastroenterologists, dermatologists or cardiologists.

When employees cannot access specialty care in a timely manner, they are more likely to rely on emergency rooms or urgent care, which drives up costs.

Employer actions: Some employers are responding by supplementing traditional plans with specialty telehealth solutions or third-party platforms that shorten wait times and improve care coordination.

Consider surveying employees to identify gaps in access and understand whether additional solutions are warranted.

Accessing plan analytics to tailor benefits

Because many organizations still design benefits based on assumptions rather than real utilization patterns, only a small share of workers report being truly satisfied with their benefits — suggesting a disconnect between what is offered and what is needed.

Employer actions: Use carrier-provided tools, if available, such as reporting dashboards, health risk assessments or plan modeling software. Review claims data at least quarterly to identify cost trends, any under- or overutilization, emerging risks or cost anomalies.

Understanding which programs are being used, where employees are falling through the cracks and which interventions are producing results allows organizations to refine benefits with greater precision and financial discipline.

The takeaway

Rising health care costs are unlikely to ease in the near term, but employers are not without options. While there are many areas that can be addressed, focusing on emerging cost-containment efforts could be a winning strategy for employers.

"medical
Uncategorized

Seven Tips for Avoiding High Medical Bills

by Inoventive Solutions
January 6, 2026

When people sign up for a new health insurance plan, be that an employer-sponsored plan or one purchased on the Affordable Care Act (ACA) exchange, they can often be confused about when coverage starts, what is covered and whether they have to share in the medical bills.

The Kaiser Family Foundation recently compiled a list of seven takeaways from stories about people who ended up paying large out-of-pocket expenses for medical care. Health plan enrollees should read the following to learn how they can better use their plan and avoid financial blowback.

1. Most insurance coverage doesn’t start immediately

Many new plans come with waiting periods, so it’s important to maintain continuous coverage until a new plan kicks in.

One exception: An employee can opt into a COBRA policy or purchase a plan on the ACA marketplace (healthcare.gov or a state-run plan in certain states) within 60 days of losing their job-based coverage. With COBRA, once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.

They will also qualify for a special enrollment period on the ACA marketplace to get coverage for the rest of the year. Coverage can start the first day of the month after someone loses their employer-sponsored coverage.

2. Check coverage before checking in

Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and cancer screenings.

Enrollees should call their insurer — or, for job-based insurance, their human resources department or retiree benefits office — and ask whether there are exclusions for the care they need, including per-day or per-policy-period caps, and what they can expect to pay out-of-pocket.

3. ‘Covered’ does not mean insurance will pay

Carefully read the fine print on network gap exceptions, prior authorizations and other insurance approvals. The terms may be limited to certain doctors, services and dates.

Also, while the service may be covered, sometimes it won’t be until the deductible or out-of-pocket maximum is met.

4. Get estimates for nonemergency procedures

Before scheduling a nonemergency procedure, an enrollee may be able to shop around among different providers that offer the procedure. Request estimates in writing and if an enrollee objects to the price, they should negotiate before undergoing care.

5. Location matters

Prices can vary depending on where a patient receives care and where tests are performed. If a patient needs blood work, they should ask their doctor to send the requisition to an in-network lab.

A doctor’s office connected to a health system, for instance, may send samples to a hospital lab, which can mean higher charges if it’s not in-network.

6. When admitted, contact the billing office early

When an enrollee or a loved one has been hospitalized, it can help to speak to a billing representative if possible. Questions to ask:

  • Has the patient been fully admitted or are they being kept under observation status?
  • Has the care been determined to be “medically necessary?”
  • If a transfer to another facility is recommended, is the ambulance service in-network or is it possible to choose one that is?

7. Ask for a discount

Medical charges are almost always higher than what insurers would pay, and providers expect them to negotiate lower rates. Health plan enrollees can also negotiate.

Uninsured or underinsured patients may be eligible for self-pay or charity care discounts.

"group
Uncategorized

ACA Subsidy Expiration Could Ripple Through Group Health Plans

by Inoventive Solutions
December 23, 2025

The expiration of enhanced premium subsidies that have helped millions of Americans afford individual health insurance through the Affordable Care Act exchanges at the end of 2025 will be felt by employers offering group health plans.

As exchange coverage becomes less affordable for many households, more workers may look to employer-sponsored plans for stability, while employers that fund Individual Coverage Health Reimbursement Arrangements (ICHRA) to help employees buy coverage may need to revisit affordability and contribution strategies because the same employer funds may cover a smaller share of premiums than before when purchasing health insurance on Healthcare.gov and other state-run exchanges.

The temporary subsidy enhancements enacted during the COVID-19 pandemic removed the 400% federal poverty level income cap and increased the value of premium tax credits across income brackets. As a result, subsidized exchange enrollment nearly doubled between 2020 and 2024. If the enhanced subsidies expire, higher-income households will lose eligibility altogether while those who remain eligible will receive smaller credits and pay more for their share of the premium.

Increasing enrollment pressure

For employers offering traditional group health coverage, one likely consequence is increased enrollment pressure. As individual premiums rise, employees who previously declined employer coverage may opt in during open enrollment.

That could affect plan participation, contribution levels and claims experience particularly if workers with higher health care needs are more motivated to seek employer coverage.

Labor dynamics could also shift. Workers without access to affordable employer-sponsored coverage may be more inclined to change jobs to secure benefits, potentially influencing recruitment and retention in competitive labor markets. At the same time, fewer employees qualifying for exchange subsidies could slightly reduce applicable large employers’ exposure to costly ACA “pay or play” penalties, which are triggered when full-time employees receive premium tax credits.

ICHRA effects

The impact may be more immediate for employers offering ICHRAs, which reimburse employees for individual market coverage rather than providing a group plan.

If subsidies shrink and marketplace premiums rise, some ICHRA allowances that were previously affordable may no longer meet regulatory affordability thresholds. Employers may need to increase contribution levels or adjust benchmark assumptions to remain compliant.

Industry experts have also warned that abrupt shifts in individual market enrollment could create volatility. A contraction in exchange enrollment — particularly if healthier individuals drop coverage — could put upward pressure on premiums, further complicating affordability for both employees and employers relying on individual-market plans.

At the same time, the uncertainty may accelerate interest in alternative benefit strategies. Employers facing steep group plan renewals may explore ICHRAs to shift risk to the broader individual market, though that strategy becomes more complex if exchange affordability deteriorates.

What employers should consider now

Now that the enhanced subsidies have expired, employers may want to:

  • Review group health plan affordability and employee contribution structures.
  • Reassess ICHRA allowance levels and benchmark plans if applicable.
  • Evaluate workforce demographics and possible enrollment shifts for 2026.
  • Prepare employee communications that explain coverage options and tradeoffs.
"health
Uncategorized

Health Benefit Trends to Watch in 2026

by Inoventive Solutions
December 16, 2025

Employers are heading into what may be one of the most challenging years for managing group health costs.

The new “Trends to Watch in 2026” report by Business Group on Health (BGH) outlines developments that will shape next year’s benefits environment. Rising medical and pharmacy spending, a rapidly changing policy landscape and increased pressure for innovation may pressure employers to revisit long-standing strategies and consider new ones.

Below are six trends the report predicts will affect health plans.

1. Affordability pressures intensify

Employers project a median 9% increase in health care costs for 2026, dropping to 7.6% after plan design adjustments. These increases follow two years of costs that ran higher than expected, signaling that inflationary pressure has become a persistent challenge.

Chronic conditions, an aging workforce, higher medical and pharmacy prices and ongoing system fragmentation all contribute to the strain. As a result, employers may need to weigh short-term mitigation tactics against longer-term structural changes, including program reductions or redesigned plan approaches.

2. Emphasis on preventive care and primary care

With chronic disease remaining the top cost driver, employers are expected to “get back to basics.” That means increasing the focus on preventive care, evidence-based screenings and stronger primary care engagement.

Many organizations will also reassess well-being and chronic-condition programs to ensure they produce measurable results. Incentives or alternative plan designs that encourage screenings, primary care use or condition management may become more common as employers push to improve long-term health trends.

3. Pharmacy costs will continue to weigh

Drug spending is one of the fastest-growing costs, driven by GLP-1 drugs, gene and cell therapies and broader price inflation. Existing mitigation strategies are losing effectiveness, prompting employers to re-examine pharmacy benefit manager (PBM) relationships, transparency, contracting terms and utilization controls.

The rise of direct-to-consumer cash prices adds another layer of complexity, as employees may seek lower-cost options outside the plan. Employers will need a clear stance on whether to support or discourage such use.

4. Streamlining and tightening vendor partnerships

As a result of years of adding new programs, many employers now face fragmented, duplicative services and inconsistent data integration. In 2026, the report predicts that employers will place vendors under greater scrutiny and focus on measurable outcomes. Vendors will be expected to improve data sharing, coordinate care with other partners and demonstrate value.

5. Faster adoption of alternative plan models

To manage rising costs, employers will continue to explore new plan structures. Options such as copay-based designs, virtual-first plans, primary care-centered models and network-less structures are gaining traction.

We can help you compare these models with traditional preferred provider organization, health maintenance organization and high-deductible health plan options.

6. Shifting policy landscape adds uncertainty

PBM reforms, updated preventive care guidelines and new chronic-disease coverage policies may influence employer plan design. Potential ACA subsidy expirations and ongoing Medicaid eligibility changes could increase reliance on employer coverage.

With the 2026 midterm elections approaching, legislative action may slow while regulatory activity increases. Employers will need to monitor these developments closely to anticipate compliance obligations and communicate changes to employees.

Takeaway

If the BGH report is accurate, many employers will be looking for ways to cut costs, boost vendor accountability and explore new plan structures.

If you are interested in alternative plan models, we can help you compare them with preferred provider organization, health maintenance organization and high-deductible health plan options.

""/
Uncategorized

How to Avoid the ‘Ghost Network’ Issue in Your Health Plans

by Inoventive Solutions
December 9, 2025

For your group health plan enrollees, finding a doctor who accepts their plan should be straightforward since each plan typically has a network of physicians available for enrollees.

However, enrollees regularly learn that a doctor that is clearly listed in their health plan’s provider list is no longer in their insurance company’s network, which can result in delayed or denied care as well as higher out-of-pocket costs. Welcome to the problem of health plan “ghost networks,” or “ghost providers,” which are usually the result of outdated provider lists.

This problem can result in employee resentment about their group health plan and saddle them with higher costs if they are forced to go out of network to seek out care. Here’s what your employees need to know if they encounter a ghost provider and are unable to access a certain medical service.

What are ghost networks?

A ghost network occurs when a health plan lists health care providers in its directory who are not actually available to enrollees. These providers may have:

  • Retired or relocated without their listings being updated.
  • Stopped accepting your health plan.
  • Reached patient capacity and are not taking new appointments.
  • Outdated contact information that prevents enrollees from reaching them.

Many insurer health plan directories are outdated. A 2023 report from the Office of Inspector General found that despite a Centers for Medicare & Medicaid Services rule requiring insurers to update their directories every 90 days, errors persisted. Some incorrect listings had remained on the network list for over a year.

Health plan enrollees who rely on inaccurate provider directories may experience:

  • Delays in care:Finding an in-network provider can take weeks or even months, potentially delaying necessary medical treatment.
  • Unexpected costs: Beneficiaries who unknowingly visit an out-of-network provider may face high out-of-pocket expenses or denied claims.
  • Frustration and confusion: Patients may have to call multiple providers, only to be told that the doctor they are trying to see does not accept their plan.

What you can do

To help your staff avoid ghost networks, train them about the importance of veryifying information provided by their insurance company. This includes checking the provider’s acceptance of new patients, their willingness to see you and ensuring they are truly in-network for your specific plan. 

They can do this by contacting the provider directly and verifying their network status and patient acceptance. 

Before seeing a new doctor or specialist and to ensure that they are not charged for going out of network, health plan enrollees can start by verifying provider information by:

  • Accessing the provider portal:   Use the insurer’s website to access their provider portal and search for specific providers you’re interested in. 
  • Directly contact the insurer: Contact the provider directly (phone, e-mail or online contact form) to confirm their willingness to accept new patients and their in-network status for your plan. 
  • Consult the provider directory: Double-check the accuracy of the insurer’s provider directory by verifying information like office locations, phone numbers, and acceptance of new patients. 

If a health plan enrollee is confronted with an inaccurate listing, they can:

  • Inform the insurer and request that it be corrected. 
  • File a grievance. If an enrollee is unable to make an appointment with a doctor listed as an in-network provider, they can ask the insurance company to help you schedule an appointment or file a grievance. 
"Prior
Uncategorized

Health Insurers Slowly Cut Prior Authorizations

by Inoventive Solutions
December 2, 2025

Health insurers pledged in June 2025 to overhaul their processes as part of a Trump administration initiative to reduce the volume of prior authorization requirements and modernize how requests are handled.

Many insurers targeted Jan. 1, 2026, for measurable reductions, but how far have they gotten? While carriers say they are making progress, provider groups such as the American Medical Association contend that little has changed for patients and clinicians on the ground.

This tension matters to employers and HR executives who sponsor group health plans because prior authorization rules influence employee access to care, administrative costs and satisfaction with their health benefits.

Why prior authorization became a flash point

Prior authorization — or prior approval — requires clinicians to secure insurer signoff before performing procedures, prescribing certain medications or ordering tests. Plans say it helps control unnecessary or low-value care.

Providers argue that approvals can take hours or days, even for routine services, leading to delayed diagnoses or treatment. News reports of patients waiting for life-saving care, sometimes with tragic outcomes, have intensified scrutiny.

The June 2025 pledge aimed to blunt these concerns and respond to growing state and federal pressure to simplify the process. Most major insurers pledged to:

  • Cut the number of medical services needing prior authorization, particularly common procedures like colonoscopies and cataract surgeries, by Jan. 1, 2026.
  • Honor existing prior authorizations for 90 days when a patient changes insurers mid-treatment.
  • Offer clearer explanations for denials and ensure all denials receive a medical review.

What the largest insurers are doing

UnitedHealthcare — The company dropped prior authorization requirements for 231 procedures in December 2025, including nuclear medicine studies, certain obstetrical ultrasounds and electrocardiography procedures. It previously reduced approval requirements for services with consistently high adherence to evidence-based guidelines.

Cigna — Cigna has eliminated prior authorization for nearly 100 services, added real-time status tools and expanded patient support teams that help members navigate approvals.

Humana — The insurer says it eliminated about one-third of outpatient prior authorizations, including for colonoscopies and certain imaging studies. It has committed to issuing decisions within one business day for at least 95% of complete electronic requests starting Jan. 1, 2026, and is working to automate approvals for most routine requests.

Aetna — Aetna is in the process of automating one in four PA approvals for near-instant decisions and using AI tools to help members navigate the system. It has started bundling multiple prior authorization requests for cancer imaging into single submissions and has expanded bundling to musculoskeletal services, certain surgeries, medications and related care.

Blue Cross Blue Shield plans — The association says BCBS plans around the country are reducing requirements and preparing January 2026 workflow changes. More detailed reporting is expected in spring 2026 as part of an industrywide dashboard.

State policy activity accelerates

States have become increasingly aggressive in regulating prior authorization, shaping reforms employers may encounter in the coming years. Recent actions include:

  • Arkansas, West Virginia and others have implemented programs that exempt high-performing physicians from prior authorization requirements.
  • Vermont requires 24-hour urgent decisions, while Virginia mandates 72-hour expedited reviews.
  • Indiana, Delaware and Oklahoma have instituted professional review standards, requiring denials to be reviewed by clinical peers or physicians with specialty expertise.
  • Maryland and Washington have instituted electronic submission mandates.
  • Wyoming and other states have implemented continuity-of-care protections that require new insurers to honor existing approvals from a prior insurer for a specified period.
  • Maine, Colorado and Alaska have codified transparency requirements, such as public reporting of approval and appeal data, clearer notices and mandated appeal instructions.

These state reforms, coupled with new federal timelines for Medicare Advantage and Medicaid starting in 2026, signal that regulatory pressure is likely to intensify.

Takeaway

Health insurers have pledged meaningful reductions in prior authorization, and the industry is watching to see what kind of changes they implement in 2026. The result should hopefully improve the health care experience for your employees, particularly those who have ongoing health issues that are expensive to treat.

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