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In an unpublished memorandum decision, the Ninth Circuit in R.R. v. California Physicians’ Service d/b/a Blue Shield of California, affirmed the insurer and administrator’s denial of benefits for a dependent’s residential mental health treatment under an ERISA‑governed plan. The court applied abuse‑of‑discretion review and concluded that the denial was supported by the plan’s medical‑necessity criteria and the administrative record. The dissent, however, argued that the majority failed to meaningfully account for a structural conflict of interest and for the administrator’s handling of treating‑provider evidence and prior failed lower levels of care.

On January 26, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2027 Advance Notice of Methodological Changes for Medicare Advantage (MA) capitation rates and Medicare Part D payment policies. CMS projects a net average year‑over‑year MA payment change of just 0.09% — roughly a flat environment once medical trend, utilization, and other pressures are considered. CMS frames the proposal as improving “payment accuracy and sustainability,” with a focus on aligning payments more closely with actual beneficiary risk and care rather than documentation intensity.

In this crossover episode of Payments Pros and The Consumer Finance Podcast, guest host Taylor Gess dives into the rapidly evolving world of point-of-sale financing for medical and dental procedures with Troutman Pepper Locke Partners Jason Cover, Brent Hoard, and Erin Whaley. They unpack how HIPAA, business associate relationships, and information-sharing structures can impact financing programs in clinical settings. They explore state-level trends in California, Illinois, and New York, including new restrictions on provider involvement in financing, promotional offers, and payments. The discussion also highlights emerging risks around website tracking technologies, payment portals, and wiretapping-style lawsuits targeting digital health and payment ecosystems. Listeners will come away with a practical framework for structuring medical and dental financing arrangements, managing disputes, and anticipating the next wave of state-level regulation and enforcement.

In this crossover episode of The Consumer Finance Podcast and Payments Pros, guest host Taylor Gess dives into the rapidly evolving world of point-of-sale financing for medical and dental procedures with Troutman Pepper Locke Partners Jason Cover, Brent Hoard, and Erin Whaley. They unpack how HIPAA, business associate relationships, and information-sharing structures can impact financing programs in clinical settings. They explore state-level trends in California, Illinois, and New York, including new restrictions on provider involvement in financing, promotional offers, and payments. The discussion also highlights emerging risks around website tracking technologies, payment portals, and wiretapping-style lawsuits targeting digital health and payment ecosystems. Listeners will come away with a practical framework for structuring medical and dental financing arrangements, managing disputes, and anticipating the next wave of state-level regulation and enforcement.

On January 7, the U.S. Court of Appeals for the First Circuit denied the federal government’s request for a stay of the nationwide preliminary injunction barring implementation of the Health Resources and Services Administration’s (HRSA) 340B Rebate Model Pilot Program. Five days later, on January 12, the Department of Justice advised the court that the parties are discussing returning the challenged approvals to HRSA for reconsideration and that they “plan to dismiss the appeal in short order,” signaling that the current version of the pilot is unlikely to move forward on appeal.

On January 12, the U.S. Supreme Court denied the petition for writ of certiorari in Guardian Flight, leaving in place the Fifth Circuit’s June 2025 decision that we covered in our prior post (available here). As a result, within the Fifth Circuit, providers cannot rely on the No Surprises Act (NSA) itself to enforce Independent Dispute Resolution (IDR) awards in court and face a heightened standing bar for ERISA-based claims where patients are insulated from financial harm. And the persuasive effect of the Fifth Circuit’s holding is bolstered nationwide.

On December 29, 2025, Chief Judge Lance Walker of the U.S. District Court for the District of Maine granted the plaintiffs’ motion for a preliminary injunction in American Hospital Association v. Kennedy. The court enjoined implementation of HRSA’s 340B Rebate Model Pilot Program “pending further order,” blocking the program from going into effect on January 1, 2026 (and April 1, 2026 for one manufacturer).

Colorado House Bill 25-1002, effective January 1, 2026, amends Colorado Revised Statutes § 10-16-104(5.5) to require health benefit plans to use nationally recognized, not-for-profit clinical criteria when making coverage and utilization review determinations for behavioral health, mental health, and substance use disorder treatment. The statute establishes a uniform approach to coverage and utilization review and tightens state-level expectations for compliance with the federal Mental Health Parity and Addiction Equity Act (MHPAEA).

A coalition of hospital associations and individual safety‑net providers recently filed suit in the U.S. District Court for the District of Maine challenging the Health Resources and Services Administration’s (HRSA) newly announced 340B Rebate Model Pilot Program, alleging violations of the Administrative Procedure Act (APA). As framed in the complaint, the program would replace the 30‑year‑old practice of offering 340B discounts at the point of sale with a post‑dispense rebate for a set of high‑volume drugs, compelling covered entities to pay wholesale acquisition cost (WAC) upfront and then pursue reimbursement from manufacturers. The plaintiffs contend the shift will impose hundreds of millions of dollars in administrative and cash‑flow costs on safety‑net hospitals, jeopardize care in rural and underserved communities, and reflect a sudden, unexplained reversal of HRSA’s longstanding position that upfront discounts are the most effective and efficient way to administer the program.

Private equity’s footprint in health care has expanded rapidly over the past decade, and in response states have begun to retool long‑standing doctrines and create new guardrails that target ownership, control, and transparency. The result is an emerging patchwork of laws and review processes that remake the corporate practice of medicine landscape, constrain common “friendly PC” structures, and require far more visibility into transactions involving private equity, hedge funds, real estate investment trusts (REITs), and management services organizations (MSOs).