March often brings thoughts of clovers, charms, and lucky breaks, but when it comes to health benefits, relying on luck is not an option. With rising healthcare costs, evolving workforce needs, and increasingly complex regulations, success requires proactive strategies and a firm commitment to compliance. Employers have significant opportunities to turn challenges into wins by addressing key focus areas thoughtfully and strategically
Here are three (3) critical takeaways to ensure health benefits strategies align with financial goals, compliance requirements, and employee well-being—no lucky charms needed.
1. Addressing the Pharmacy Cost Challenge: Finding the Pot of Gold in Savings
Pharmacy costs now consume a significant share of healthcare budgets, driven by high-cost specialty drugs and opaque pharmacy benefit manager (PBM) practices. While these challenges can feel overwhelming, the right strategy can uncover substantial savings, akin to finding a pot of gold at the end of a rainbow.
Compliance Considerations:
The Lower Costs, More Transparency Act mandates detailed reporting on rebates, drug spending, and formulary decisions. Employers must ensure PBM contracts comply with these requirements to avoid penalties.
ERISA fiduciary duties require careful monitoring of PBM compensation structures to safeguard plan assets and avoid legal exposure. Prescription drug data collection (RxDC) obligations necessitate timely reporting to meet regulatory standards.
Strategic Steps:
Partner with transparent PBMs to eliminate hidden fees and maximize rebate pass-through, reducing unnecessary expenses. Audit PBM contracts regularly to ensure alignment with regulatory changes and plan goals. Explore specialty pharmacy agreements or international drug sourcing as alternative cost-saving measures. Employers don’t need luck to manage pharmacy costs—they need clear contracts, compliance, and creative approaches.
2. Enhancing Mental Health Access: Removing Barriers to Well-Being
Mental health remains a top priority, with greater demand for accessible and affordable care options. Addressing these needs is not about leaving things to chance—it’s about building thoughtful systems to support employees’ well-being while ensuring compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA).
Compliance Considerations:
Updated MHPAEA regulations require rigorous documentation of treatment limits, ensuring parity between mental health and medical/surgical benefits. Fiduciary certifications under ERISA compel plan sponsors to demonstrate compliance with mental health parity laws. Transparent provider networks are essential to meet both legal requirements and employee expectations for access.
Strategic Steps:
Expand telehealth and virtual counseling options, ensuring widespread access to mental health services. Waive or reduce financial barriers like copays for mental health visits to encourage utilization. Embed on-site counselors in workplaces to provide immediate, convenient care. Employers that proactively address mental health create a culture of support, proving that strategy—not luck—is the key to long-term success.
Rising Costs and Regulatory Complexity: Avoiding Unlucky Surprises
Healthcare costs are increasing at unprecedented rates, and the regulatory landscape continues to evolve. Employers who plan ahead can mitigate cost pressures and avoid compliance pitfalls, ensuring their benefits strategies stay on solid ground.
Compliance Considerations:
The Transparency in Coverage (TiC) rule demands cost-comparison tools and updated machine-readable files to provide employees with clear cost information. ACA preventive services mandates require ongoing updates to benefit designs, including newly recommended screenings or medications. Multistate operations face additional challenges from state-specific laws targeting PBM practices, paid leave, and other benefits.
Strategic Steps:
Work with compliance teams to ensure adherence to ACA, TiC, and state-level mandates. Leverage direct provider contracting to secure predictable pricing and reduce reliance on intermediaries. Use data analytics to identify wasteful spending and direct resources to high-value care. A well-prepared compliance strategy ensures health benefits are resilient against rising costs and regulatory changes. It’s not about being lucky—it’s about being ready.
Compliance and Leadership: The Real Four-Leaf Clover
Success in health benefits isn’t about hoping for the best or waiting for lucky breaks. It’s about crafting a plan that aligns with regulatory requirements, controls costs, and supports employee well-being. Employers who integrate compliance into their strategies unlock transparency, equity, and sustainability—no charms required.
As the saying goes: You can’t pay less for healthcare unless you pay less for healthcare. By addressing pharmacy costs, mental health parity, and compliance challenges, organizations can create a benefits program that delivers meaningful results.
Transparent Health Benefits (THB) is here to guide organizations through the complexities of modern health benefits. With education in compliance, cost management, and innovative strategies, THB ensures employers don’t leave their success to luck—they create it.
References
• Business Group on Health. (2024). 2025 employer health care strategy survey: Perspectives on health care.
• Business Group on Health. (2024). 2025 employer health care strategy survey: Pharmacy costs.
• Business Group on Health. (2024). 2025 employer health care strategy survey: Mental health design.
• U.S. Department of Labor. (2024). Mental health parity and addiction equity act compliance guidelines.
• Centers for Medicare & Medicaid Services. (2024). Transparency in coverage rules.
