Life and Health News
January 2026
Welcome to our latest newsletter! As a thought leader in the Insurance Industry for over 50 years we are always excited to share the latest sampling of insurance compliance related bulletins, regulations, and legislative activity. Please feel free to share this newsletter with others that may be interested. Contact Us with any questions on the items in this newsletter or with any other compliance related matter we can assist you with. Enjoy!
AFFORDABLE CARE ACT
New York released guidance clarifying grace periods, claims handling, and payment methods for ACA-compliant individual and small group plans in the NYSOH marketplace. Insureds receiving APTC have a 90-day grace period with specific claim payment rules, while those without APTC have a 30-day period; partial payments may be allowed under a 95% threshold, with shortfalls applied to future premiums. Plans must notify providers, prevent balance billing during grace periods, and accept multiple payment methods. Filing Guidance Dated 12/4/25
ARTIFICIAL INTELLIGENCE
Hawaii issued a memorandum providing guidance on the responsible use of Artificial Intelligence (AI) systems by insurers, emphasizing compliance with state laws on unfair trade practices, discrimination, and market conduct. Insurers are required to develop and maintain an AIS Program addressing governance, risk management, internal audits, transparency, and consumer protections, including oversight of third-party AI systems, documentation, and validation processes. Memorandum 2025-13A
DENTAL INSURANCE
Kentucky issued a bulletin guiding implementation of HB 210, establishing a uniform dental benefit assignment form that allows covered persons to assign dental insurance payments to out-of-network providers. The form outlines provider and insurer obligations, including notices, refunds, and revocation rights, while clarifying that carriers must honor assignments, but covered persons remain responsible for cost-sharing and uncovered charges. Bulletin 2025-05
FILING REQUIREMENTS / PROCEDURES
Hawaii announced the reorganization of the Insurance Division’s Rate and Policy Analysis Branch into two specialized units: the Life and Accident & Health Filings Branch and the Property and Casualty Filings Branch. The restructuring aims to improve regulatory oversight, enhance the timeliness and quality of filing reviews, and align the division’s operations with industry best practices. Memorandum 2025-12R
Maryland issued a bulletin providing guidance on form and rate filing requirements for student health benefit plans for the 2026–2027 school year. Insurers must submit filings for new or amended forms or rate changes by February 2, 2026, ensuring compliance with federal and state laws, including step therapy limits, preventive service guidelines, copay accumulator rules, MHPAEA, and PPACA rating requirements, while demonstrating essential health benefit coverage and minimum actuarial value. Bulletin 25-17
HEALTH INSURANCE / HEALTH RATES
Arizona released guidance to insurers marketing and selling Short-Term, Limited Duration Insurance (STLDI) plans, clarifying enforcement of federal notice requirements and compliance expectations following recent federal agency guidance and rule changes. The Department of Insurance will enforce enhanced consumer notice and disclosure requirements but will not enforce federal term and duration limits, while emphasizing transparency, consumer education, and prohibitions on marketing STLDI as comprehensive major medical coverage. Bulletin 2025-12 (INS)
New Jersey clarified that carriers must continue to cover childhood immunizations, including the hepatitis B vaccine at birth, as recommended by the New Jersey Department of Health, without cost-sharing or additional barriers. Carriers may not impose prior authorization, restrictive site-of-service policies, or other administrative requirements that limit access, and are expected to encourage plan sponsors of non-state-regulated plans to follow these standards. Bulletin 25-11
Vermont updated Bulletin 171 to clarify the application of out-of-pocket maximums for prescription drugs under Insurance Code Section T.8 §4092. The bulletin provides FAQs addressing which drugs and expenses count toward out-of-pocket limits, how the rules apply to HDHPs and Health Savings Accounts, plan applicability, and references IRS guidance for dollar thresholds. Bulletin 171 (Revised)
HOLDING COMPANIES
Mississippi amended its insurance holding company regulation to align with the NAIC Model, updating requirements for cost-sharing and management service agreements and establishing provisions for group capital calculations. Changes include exemptions and limited filings for the annual group capital calculation, criteria for recognizing non-U.S. jurisdictions, and renumbering provisions concerning adequacy of surplus, with all new and renewal reinsurance transactions after July 1, 2017, required to comply. 19-1-20.19
INTERNAL AND EXTERNAL REVIEW
California issued an All-Plan Letter notifying licensed health plans that Managed Medical Review Organization, Inc. (MMRO) has been added as a contractor, alongside MAXIMUS, Inc., to conduct Independent Medical Reviews under existing statutes and regulations. The IMR process itself remains unchanged, and plans must continue to provide required records and documents within applicable timeframes. DMHC APL 25-017
MEDICARE SUPPLEMENT INSURANCE
Colorado issued a bulletin addressing unfair trade practices related to Medicare Advantage and Medicare Supplement products, clarifying that actions restricting enrollment access or manipulating producer compensation may violate state insurance law. The bulletin applies to all carriers and producers and requires insurers to maintain accessible enrollment applications, avoid discouraging sales or enrollment, and adhere to approved compensation structures. Bulletin B-4.157
Vermont released a notice explaining guaranteed issue rights and Medicare Supplement plan options for individuals in different scenarios, as many insurers have exited the state’s Medicare Advantage marketplace. Coverage availability depends on when a person became eligible for Medicare and includes special rules for newly eligible individuals, who have a six-month guaranteed issue window around their 65th birthday (or 24 months after a disability determination). Notice Dated 11/25/25
MISCELLANEOUS HEALTH / ACCIDENT
California issued an All-Plan Letter addressing amendments to network adequacy standards and methodologies affecting the 2026 Annual Network Review, including updates for mental health network availability, out-of-network care arrangements, provider data accuracy, and block transfer requirements. The guidance clarifies definitions, updates regulatory citations, and instructs plans to revise documentation and submit required filings through the DMHC e-Filing portal. DMHC APL 25-
OMNIBUS LEGISLATION
Illinois updated multiple sections of its Insurance Code to expand preventive health coverage, mandate vaccination administration fee coverage, strengthen PBM contract and reporting requirements, clarify licensure and refund processes, define unfair insurance practices, update pharmacy practice definitions, and establish a pharmacy support grant program. The changes include cost-sharing protections for immunizations, restrictions on PBM practices and drug access, updated reporting and licensure obligations, and grants to improve pharmacy access in underserved areas. HB 767
PHARMACY BENEFIT MANAGERS
Alaska issued a bulletin providing guidance on SB 132, updating licensing, fees, definitions, and examination requirements for Pharmacy Benefits Managers, Third-Party Administrators, Independent Adjusters, and other insurance entities to promote compliance and national uniformity. The bulletin establishes new PBM and TPA licensure standards, expands nonresident and designated home state licensing for independent adjusters, removes certain exemptions and physical location requirements, and updates lines of authority and compliance officer rules. Bulletin B 25-09
Arizona adopted Article 25 establishing licensing, operational, compliance, and recordkeeping standards for pharmacy benefit managers, including certificate of authority requirements, biennial renewals, utilization review obligations, and defined record-retention periods. The rules set a $500 non-refundable application and renewal fee, require notices for material modifications, and add specific licensing review timeframes to enhance transparency and regulatory oversight. R20-6-708 Table A
Colorado amended its regulations to require all pharmacy benefit managers operating in the state to register annually with the Division of Insurance and to clarify related compliance and enforcement procedures. The amendment updates the regulation’s effective date provisions and corresponding history section to reflect the revised implementation timeline. 3 CCR 702 Reg. 4-2-97 s 12
Illinois released a bulletin to provide guidance on the Prescription Drug Affordability Act, clarifying PBM reporting and fee obligations. PBMs must file annual reports on covered individuals and pay $15 per Illinois resident covered under administered plans, with enforcement temporarily deferred pending the enactment of HB 767, which further clarifies applicability, reporting requirements, and eligibility for credits or refunds. The bulletin specifies which plans are subject to the PDAA and provides instructions for submissions once HB 767 becomes law. Bulletin 2025-20
Kentucky amended its regulations to enhance licensure, renewal, and oversight requirements for pharmacy benefit managers, including updated fees, financial responsibility standards, and reporting obligations. PBMs must pay a $10,000 registration fee (with certain exemptions), maintain evidence of financial responsibility of at least $1,000,000, and comply with clarified renewal procedures. Additionally, the regulation incorporates the updated Pharmacy Benefit Manager License Application form. 806 KAR 9:360
Kentucky issued a revised bulletin providing guidance on the implementation and enforcement of SB 188 for pharmacy benefit contracts. The bulletin clarifies ERISA preemption, confirming that minimum pharmacy reimbursement rates are enforceable while anti-steering provisions are preempted. Bulletin 2025-03
Louisiana issued guidance on Act 474, establishing new reimbursement requirements for PBMs and health insurers contracting with PBMs. The law requires PBMs to use a reimbursement formula incorporating a prescription drug pricing benchmark (NADAC or an approved alternative), an adjustment factor to limit claim payment errors to 2% per drug, and a professional dispensing fee reflecting industry standards, with recommended markups and quarterly adjustments. Advisory Letter 2025-05
REGULATORY REPORTING REQUIREMENTS
Rhode Island summarized its 2026 annual and quarterly filing requirements for domestic and foreign health insurers. Insurers must follow the NAIC General Instructions, Health Insurers Checklist, and the Division’s Notes and Instructions, submitting required filings electronically to the Insurance Division (or Division of Taxation for premium taxes) by the specified due dates, while excluding unrelated items like annual statements, renewal fees, or retaliatory assessments. Filing Requirements 2026 Health
REPORTS - DATA CALLS & OTHER REPORTS
Colorado issued a revised bulletin requiring life, health, and private passenger auto insurers that do not use External Consumer Data and Information Sources (ECDIS), algorithms, or predictive models to submit annual attestations confirming non-use. Bulletin B-10.001
RISK-BASED CAPITAL
New York issued guidance for insurance companies on submitting Actuarial Opinions, Memoranda, and Risk-Based Capital Checklists, detailing filing requirements, deadlines, and submission procedures. Actuarial Opinions are due March 1, with checklists submitted by the Appointed Actuary via email for each legal entity, covering multiple regulations and specifying additional filings for MVA annuities, Universal Life with Secondary Guarantees, 2001 CSO Preferred Mortality Tables, and Variable Annuity Option Value Floor Reports. AOM and Risk Based Capital Checklist