Recently, the Sixth Circuit issued a significant ERISA preemption ruling for employers and pharmacy benefit managers (PBMs). The court held that Tennessee’s PBM laws, which require “any willing” pharmacy access and limiting incentives that steer members to plan‑favored pharmacies, are preempted as applied to self‑funded ERISA plans. The ruling draws a clear line between permissible PBM cost regulation and impermissible interference with plan design and administration.
The Fourth Circuit has affirmed a preliminary injunction barring enforcement of West Virginia’s S.B. 325, which sought to restrict how drug manufacturers implement contract pharmacy policies under the federal 340B Drug Pricing Program. In a published decision, the court held that manufacturers are likely to succeed on their claim that S.B. 325 is preempted because it impermissibly rewrites the “bargain” Congress struck with manufacturers under its spending power and interferes with the Health and Human Services’ (HHS) exclusive enforcement role.
On March 20, Federal Trade Commission (FTC) Chairman Andrew N. Ferguson issued a memorandum directing the creation of an internal Healthcare Task Force. The directive underscores that healthcare remains a top enforcement and policy priority for the FTC, reflecting the Administration’s focus on a “more competitive, innovative, affordable, and higher quality healthcare system.”
In an unpublished memorandum decision, the Ninth Circuit in R.R. v. California Physicians’ Service d/b/a Blue Shield of California, affirmed the insurer and administrator’s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).