The Yin and Yang of the Current Benefits Moment

I am fresh off attending my 22nd Council Employee Benefits Leadership Forum (EBLF).

After every conference, I feel both buoyant and burdened—lifted by the conversations and the evidence of tangible progress it feels like we are making to create tools that will allow you to better optimize your client group benefit plans and make them more effective and economically efficient, but ever more cognizant of the hills yet to climb. This year is no different.

The Yin. On the positive side of the ledger, The Council’s 15-year campaign to make all elements of the U.S. healthcare financing system transparent appears to be bearing fruit. Legislation has been enacted and many applicable rules have been finalized. Although this remains a work in progress, an emerging tier of data analytics providers—who were out in force at EBLF—appears to be taking advantage of the new transparency framework and the rapidly expanding data trove it is generating. This framework includes the following:

The Transparency in Coverage Rule requires all health insurers and group health plans to publicly post three machine-readable files on their website:

• An in-network rate file that includes all applicable provider rates (negotiated rates, underlying fee schedule rates, derived amounts)
• An out-of-network allowed amount file that includes all unique out-of-network allowed amounts and billed charges
• A prescription drug file of all negotiated rates and historical net prices for covered prescription drugs

The rule also requires health insurance plans and issuers to maintain an online price-comparison tool that enables consumers to see price and cost information for 500 common healthcare services and items.

The Hospital Transparency Rule requires all hospitals to establish, update, and publicly post a list of their standard charges for items and services both as a comprehensive machine-readable file and in a display of shoppable services in a consumer-friendly format.

Rule Developments have occurred. Federal courts have upheld both rules in challenges brought by pharmacy benefit manager (PBM) and hospital trade associations. The Trump administration also has been active. First, a February 2025 executive order from President Donald Trump improved both regimes by requiring more frequent, usable, and accurate data reporting. Second, in May, the Centers for Medicare & Medicaid Services (CMS) reportedly sent letters informing 519 hospitals that their Transparency Rule disclosures are inadequate; the letters included either instructions on steps that should be taken to correct the deficiencies or a demand for the submission of a formal corrective action plan.

Consolidated Appropriations Act (CAA) of 2021 Section 204 Prescription Drug and Health Care Spending provisions and their implementing regulations require health insurance issuers and group health plans to annually submit to the Departments of Labor, Health and Human Services, and Treasury information regarding plan participants’ prescription drug and healthcare spending, along with detailing procedural requirements on how those filing obligations may be delegated to third-party administrators (TPAs) and PBMs.

CAA 2021 Section 202 Broker and Consultant Compensation Disclosure requires plan fiduciaries to collect precontract direct and indirect compensation information from service providers to evaluate the reasonableness of their compensation for services rendered.

CAA 2026 Section 6702 Service Provider Compensation Disclosure clarifies that the CAA 2021 Section 202 provisions apply to all plan service providers, expressly including TPAs and PBMs (a Council legislative priority).

CAA 2026 Section 6701 PBM Transparency provisions bar plan fiduciaries, starting in 2028, from contracting with a PBM unless the PBM provides regular drug-level reporting for large employer plans and plan-level summary information for all group health plans, regardless of size. The extensive data that PBMs must report to large employer plans (i.e., employers with an average of 100 employees during the preceding calendar or plan year and at least one employee on the first day of the calendar or plan year) includes:

• Compensation paid to the PBM and to pharmacies and the spread amount (i.e., the difference between these two values)
• Drug names and distribution channels
• Wholesale acquisition costs for brand name drugs
• Average wholesale price for generic drugs
• Claims count, participants served, dosage units, days’ supply
• Net price of drug after rebates
• Participants’ out-of-pocket spending
• Total plan spending
• Relationships with affiliated pharmacies

PBMs also must report to large employers detailed data on therapeutic classes, high-cost drugs, and additional affiliate pharmacy disclosures.

For all group health plans, regardless of size, PBMs must provide plan-level summary information that includes net prices, costs per claim, fee structures, and other metrics; a participant-facing summary with aggregate data; plan-level drug spending, rebates, and remuneration; and detailed drug-level and payment-level reports every six months (or quarterly upon request). These reports must be in a standardized format, in plain language, and machine readable.

State All-Payer Claims Databases (APCDs). According to data collected by the APCD Council, 25 states maintain APCDs that require all payers of health claims to submit claims and enrollment information, and an additional five states have voluntary APCD platforms. In 2016, however, the U.S. Supreme Court held in Gobeille v. Liberty Mutual that state governments could not compel self-insured employer plans regulated under ERISA to submit data to APCDs; it appears that self-insured submissions since 2016 have been relatively minimal.

At EBLF, I met with multiple data analytics providers that are selling the promise that they can use the data from all of these sources to evaluate both health and prescription drug plan performance, and that they are working with broker partners to try to optimize plan and provider platforms via this data. Many Council member firms appear to be working with these vendors and/or to be deploying similar in-house capabilities.

Insurance is the original big data business but, historically, carriers have effectively controlled that information. Our transparency campaign thesis was that democratizing access to benefits-related data would empower our broker members to assist their plan clients in offering the most effective and economically efficient solutions possible.

Some data—like that required to be made public under the CAA 2026 PBM transparency provisions—is not yet being disclosed but will be. Data uniformity and accessibility issues persist under some of the other frameworks, but those are being resolved either through processing improvements or regulatory clarifications.

That said, I have two overarching questions for which we covet input: first, what remains to be done at the public policy level, if anything, to complete our transparency agenda? Second, was our thesis correct? Are you better able to work with your plan clients to develop more effective and efficient benefits solutions now and do you think that we are on the right trajectory to fully realize the promise of transparency?

The Yang. The other side of the ledger is this—we are acutely aware that transparency is part of but not even close to the entire solution to ensuring that employer group benefit plans can be efficient and affordable. It does not, for example, address some of the overwhelming provider or high case/individual claim cost issues. On the latter, we are hard at work on a self-insured plan affordability project—our next great hill to climb. We’ll leave that burden for next month’s discussion. For now, can we revel in the interim success of our transparency agenda, or is that misdirected and fanciful? I really would like to hear your candid assessments.

As always—more to come.