LEGISLATIVE TOPICS

Consolidated Appropriations Act of 2021 (CAA) – Updated with additional FAQ Part 69 addressing restrictions on access to de-identified data under the gag clause prohibition.

No Surprises Act – Updated with information on FAQ Part 71 addressing the NSA and limitations on cost sharing under the ACA. 

Medicare - 2025 premiums, deductible and copayments were updated.  Information on changes to coverage for telehealth services. 

Affordable Care Act Overview – Additional FAQs released by EBSA were added.

Affordable Care Act and Lifetime/Annual Limits – Updated with the 2026 cost sharing limits for non-grandfathered plans.  Updated with information on the proposed rule to prohibit issuers of coverage subject to essential health benefits requirements from providing coverage for sex-trait modification as an EHB. 

Affordable Care Act and Preventive Care – Updated with information on ruling from the Supreme Court affirming the authority of the U.S. Preventive Services Task Force to issue preventive care recommendations.

Inflation Reduction Act Overview – Information added on the final rulemaking for the Medicare Prescription Drug Inflation Rebate Program.   

State Assessments on Health Related Claims - Updated with current assessment information by state.

Legal Actions Available to Claimants – Updated with information on the Chevron deference doctrine.

Mental Health Parity Acts of 1996 and 2008 – Information added on the impact of the new final rules implementing the MHPAEA was added.

HIPAA & ACA Standards for Electronic Data Interchange – Information added on the proposed rule to modify the HIPAA Security Rule to better protect electronic health data from cybersecurity threats.

Flexible Benefits Administration - Maximum HAS/HRA contribution amounts and HDHP minimum deductible and out of pocket limits for 2026 were updated.  Information on the impact of The One Big Beautiful Bill Act, which provided that HDHPs can permanently cover telehealth services before the deductible is reached.

Privacy and Confidentiality – Information on a federal district court vacating a significant portion of the HIPAA Privacy Rule to Support Reproductive Health Care Privacy Final Rule on 6/18/25. 

Women’s Health and Cancer Rights Act of 1998 – Information added on ACA FAQ Part #68 which clarified that WHCRA plans that cover mastectomies are required to provide coverage for chest wall reconstruction with aesthetic flat closure as a type of breast reconstruction.

Ambulance/Transportation Services – Updated with information on ACA FAQ #69 which included clarification as to how plans should calculate required timeframes when an initial payment or notice of denial of payment is sent electronically and the required disclosures are sent in paper form.   

Eligibility Overview – Information added on HHS rescinding prior guidance which as issued to ensure minors could access gender affirming care without discrimination under Section 1557 of the ACA.

ERISA – Information added on the dismissal of a lawsuit against Johnson & Johnson related to the allegation of mismanagement of drug benefits leading to exorbitant overpayments for generic drugs.

PROCEDURAL TOPICS

Coding & Billing - Updated with information the latest release of the ICD-10, CPT-4 and CDT-2025.  A new place of service code, 66-Programs of All-Inclusive Care for the Elderly, was added to the CMS-1500.

Occupational, Physical and Speech Therapy – Updated with 2025 threshold amounts for use with the KX modifier.

STD - Other Disability Income Sources - Disability benefits by state were updated.

STD Benefit Taxation - The Social Security taxable wage base was updated.

Dental Plan Overview – Procedures requiring submission of X-rays or periodontal charting were updated.  

Dental Topics –Coding was updated.  Additional covered and non-covered services were added. 

MEDICAL TOPICS

AIDS – Updated with Medicare coverage of pre-exposure prophylaxis (PrEP) to prevent HIV in individuals at increased risk of HIV acquisition.

Cochlear Implants and Auditory Brainstem Implants – Updated with coverage information for vestibular evoked myogenic potential for predicting post-operative complications to cochlear implantation. 

RSV Prophylactic Measures – Updated with information on Arexvy and Abrysvo for prevention of lower respiratory tract disease caused by RSV.   

Spinal Surgery/Procedures – Updated with additional investigational services.

Vaccines/Immunizations - Updated with current information on the CDC’s Recommended Immunizations Schedules.

Biofeedback - Updated with additional investigational services.

Eye Surgery - Updated with additional investigational services.

Endometrial Ablation – Updated with information on FDA approval of Minitouch 3.8 Era System.

Prosthetic Devices - Updated with additional investigational services.

Cardiac Rehabilitation Programs – Updated with coverage information of intensive cardiac rehabilitation programs.

Transplants – Updated with Medicare coverage of allogeneic hematopoietic stem cell transplant using bone marrow, peripheral blood or umbilical cord blood stem cell products for patients with myelodysplastic syndromes who have specific prognostic risk scores.

OPERATIONAL TOPICS

Vendor Selection & Monitoring – Additional information added on selecting and monitoring service plan providers and determining reasonableness of fees.  

Health Plan Compliance Checklists – Updated with information on compliance checklists. 

Claim System Considerations – Claim system vendor chart was updated.

Product Liability – New information on resources to investigate product recalls was added.   

LISTINGS AND DIRECTORIES

Internet Sites – Links were updated.