October 2025 Regulatory & Legislative Update

This regulatory and legislative update covers issues involving open enrollment considerations, the Arkansas pharmacy rule, gender affirmation, and more.

Open Enrollment Points to Consider

Health plan open enrollment is an opportunity to ensure that plans are complying with the many standards to which they are subject. Following is a brief outline of some of the points to consider.

Preventive Services

The ACA requires first-dollar coverage of certain preventive services. Periodically, these preventive services are updated. The updated list of preventive services can be found here. Generally, when a new standard is initiated, a plan must comply at the beginning of the plan year that is one year following the recommendation.

For 2026 plan years, some highlights of new preventive services are:

• Screening and Counseling for Intimate Partner and Domestic Violence
  • Annual screening for interpersonal and domestic violence for adolescents and women.
  • Services include counseling, education, and related referrals for support.
• Breast Cancer Screening for Women at Average Risk
  • Women with average risk of breast cancer should have a mammography no earlier than age 40 years and no later than age 50 years.
  • Screening mammography at least biennially and as frequently as annually.
  • Additional imaging may include MRI, ultrasound, and additional mammography
    if indicated.
• Patient Navigation Services for Breast and Cervical Cancer Screening
  • Increase use of recommended screening based on individual patient needs.
  • Patient navigation involves person-to-person interaction with a patient.
  • This service will assist individuals with access to screening and follow-up care for both breast and cervical cancers.
    • The guidelines keep the recommendation for screening for cervical cancer for average-risk women aged 21-65.

In addition to the HRSA making recommendations and updates, the Advisory Committee on Immunization Practices (ACIP) has been meeting to discuss recommendations related to immunizations. Recently, they recommended that the decision on whether or not to get the COVID-19 immunization should be a shared decision made in consultation with a healthcare provider, defined broadly to include, by way of example, a doctor, physician assistant, nurse practitioner, or pharmacist. At the time of this writing, we are still awaiting CDC approval of this guidance.

Annual Communications to Employees

Plan communication is an essential part of ensuring that employees understand the benefits to which they are entitled. There are several notices that are required to be provided annually, and several others for which it may be a best practice to provide annually. 

Annual notices include:

• Medicare Part D Notice of Creditable/Non-Creditable Coverage
  • Annually by October 15
• Children’s Health Insurance Program (CHIP) Notice
  • Annually, best practice is to provide with other required annual notices
• Women’s Health and Cancer Rights Act (WHCRA) Notice
  • Annually, best practice is to provide with other required annual notices
• Summary of Benefits and Coverage

Recommended best practice notices include:

• HIPAA Special Enrollment Notice
  • Annually, best practice is to provide with other required annual notices
• Primary Care Provider Patient Protection Notice
  • Annually, best practice is to provide with SPD
• ADA Wellness Program Notice
  • Required if wellness plan collects medical information or requires physical exam
  • Best practice is to provide annually with other materials

For a full list of plan notices, contact your CBIZ representative.

Arkansas Pharmacy Rule Survives Challenge

A federal judge in Illinois has dismissed a challenge to Arkansas’ pharmacy benefit manager rule.  As background, Central States, Southeast and Southwest Areas Health and Welfare Fund brought a suit against the former Arkansas Insurance Commissioner, Alan McCLain, arguing that Arkansas’ new law requiring health plans to report pharmacy cost information and pay a minimum amount violated ERISA. 

The Arkansas law, known as Arkansas Rule 128, allows the commissioner to review and increase a plan’s pharmacy reimbursements if they are found not to be “fair and reasonable.”  The plaintiffs argued the Rule interferes with plans governed by ERISA by imposing reporting obligations that add to the burden of administering plans and by dictating plan design by the mandatory fee structure.

The Illinois Court disagreed and found the rule applies broadly to all health plans and payers, not just those covered by ERISA. The judge stated that, in order for ERISA to apply, the law must act “immediately and exclusively” on ERISA plans, a criterion the Arkansas law does not meet. The Court also found the reporting requirement to be incidental to the core function of the regulation of fees and not related to plan administration.

Practically speaking, this means if your prescription drug plan covers any Arkansas residents, make certain to work closely with your insurer, PBM, or similar vendor to ensure that the Rule 128 reporting is accomplished.

Gender Affirmation and the 11th Circuit

The U.S. Court of Appeals for the Eleventh Circuit ruled on Sept. 9, 2025, in Anna Lange v. Houston County, Georgia, et. al., that denying coverage for surgery related to gender-affirming care is not discriminatory. 

As background, the plaintiff has worked for the Houston County Sheriff’s Office in Georgia since 2006. Plaintiff began undergoing hormone replacement therapy in 2017, along with other treatments and therapies related to conversion — all of which were covered by the County’s health plan. When the plaintiff sought gender-affirming surgery, coverage was denied based on the County’s exclusion for gender-affirming procedures. Specifically, the plan excludes drugs for sex change surgery and services and supplies for sex change and/or the reversal of a sex change procedure. 

As a result of the denial, the plaintiff filed a discrimination complaint with the EEOC and subsequently filed a lawsuit, alleging the exclusion under the plan was discriminatory on the basis of gender identity, stating that under Title VII, this was sex discrimination. Summary judgment was granted by the district court in favor of the plaintiff. The County appealed that decision, and the Appeals Court ruled to hear the case by the full court en banc. The parties were directed to brief the issue of whether the County’s plan violated Title VII.

The Eleventh Circuit’s en banc opinion reversed holding that the exclusions did not rise to the level of sex discrimination under Title VII since the exclusion was applied to all individuals, regardless of sex or gender identity. The Court based much of its decision on United States v. Skrmetti. See our past Benefit Beat article here.

Employers should consult with counsel to determine if any express protections or exclusions exist in their plans related to gender identity or gender affirming care and stay informed on any state laws or regulations related to gender that may require changes or updates to plans.

Parental NICU Leave in Illinois

Beginning June 1, 2026, Illinois’ Family Neonatal Intensive Care Leave Act requires employers to provide unpaid parental leave to employees with a child who is a patient in a Neonatal Intensive Care Unit (NICU). Employers with 16 to 50 employees must provide up to 10 days, and employers with 51 or more employees must provide up to 20 days of unpaid leave per year.

Employees may choose to take NICU leave continuously or intermittently. For intermittent leave, employers may require that leave be taken in minimum increments of not less than two hours.  Employees eligible for leave under the federal FMLA must first exhaust their available FMLA entitlement before taking leave under this Act. An employee may choose to substitute any available paid leave for unpaid leave, but the employer cannot require it.

An employee must be reinstated to his or her former position or a substantially equivalent one with no loss of benefits held or accrued prior to taking leave. The employee must be allowed to keep health coverage in effect during the leave.

Employers may require reasonable verification of the employee’s child’s length of stay in the NICU, but cannot request confidential medical information in support of the leave.

Dependent Parent Health Coverage in Illinois

Beginning Jan. 1, 2026, health plans in Illinois must allow coverage of a dependent parent or stepparent, if the parent or stepparent meets the definition of a qualifying relative under federal law.

Qualifying relative means: a relative of the taxpayer other than a spouse, who resides with the taxpayer, the taxpayer provides more than 50% of total support, and is not a qualifying child of another taxpayer.

Michigan’s No Fault Auto Coverage

Michigan law allows the purchase of various levels of auto insurance and personal injury protection (PIP). Individuals with qualified health coverage (QHC) or enrollment in Medicare Parts A and B are eligible to opt out of purchasing PIP medical coverage. 

An employer’s health plan is qualifying health coverage if it does not exclude injuries resulting from an auto accident and, for the period July 1, 2025, through June 30, 2026, has a deductible that is $6,579 or less. Deductibles are adjusted periodically, typically annually on July 1.

Insurers must advise insureds about whether employer coverage is QHC. A self-funded plan subject to ERISA is not required to provide this notice, but an employer may be asked by an employee for the information. 

The notice should provide the following:

• Names and birth dates of insureds;
• A statement that the plan is a QHC; or
• A statement that the plan does not exclude coverage for injuries resulting from motor vehicle accidents and that the deductible for the period 7/1/25 through 6/30/26 is lower than $6,579.

The information contained in this Benefit Beat is not intended to be legal, accounting, or other professional advice, nor are these comments directed to specific situations. This information is provided as general guidance and may be affected by changes in law or regulation. This information is not intended to replace or substitute for accounting or other professional advice. You must consult your own attorney or tax advisor for assistance in specific situations. This information is provided as-is, with no warranties of any kind. CBIZ shall not be liable for any damages whatsoever in connection with its use and assumes no obligation to inform the reader of any changes in laws or other factors that could affect the information contained herein.