Blue Cross Blue Shield Plan Settles Suit for $100M to Keep New Jersey State Contract, Then Gives Board Seat to Governor’s Key Adviser

By Luke Sullivan – Executives at Horizon Blue Cross and Blue Shield have a lot to be thankful for this year after settling a lawsuit with New Jersey to preserve its multi-billion contract with the state. Just before Thanksgiving, the office of the New Jersey attorney general announced it had reached a $100 million settlement with Horizon, settling years of allegations by the state that the insurer, acting as a third-party administrator (TPA) for the state, overcharged taxpayers to administer health benefits for public employees. Read Full Article...

HVBA Article Summary

1. Horizon Agreed to a $100 Million Settlement Without Admitting Fault: Horizon Blue Cross Blue Shield of New Jersey settled with the state for $100 million after being accused of submitting over 1,000 false claims and inflating charges. Between 2020 and 2024, the company managed $62.8 billion in health care charges and received nearly $500 million in administrative fees. Despite the size of the settlement, Horizon denied any wrongdoing and accused the Attorney General of distorting the facts. The company will retain its contract but must improve internal systems and increase transparency with lawmakers.

2. Allegations of Misrepresentation and Inflated Charges: The state alleged Horizon misrepresented its cost-saving capabilities to win the 2019 public health benefits contract. Under the agreement, Horizon was required to charge the lower of either provider rates or negotiated rates but allegedly charged higher amounts instead. A 2021 internal complaint claimed the company overcharged the state by $34 million, but it was reportedly dismissed at the time. The recent settlement closes that case, even as Horizon profited further from similar contracts with local governments.

3. Political Fallout and Criticism Over Governance and Transparency
   Days after the settlement, Governor Phil Murphy appointed his close adviser, Mahen Gunaratna, to Horizon’s board despite his limited health care experience. Gunaratna will reportedly be paid over $100,000, sparking backlash from watchdogs who view the move as politically motivated. Critics argue the appointment reflects deeper issues of revolving-door politics between government and health care companies. This comes as New Jersey’s public employee health plan faces insolvency and looming premium hikes.

CVS agrees to pay $38M to settle insulin fraud claims

By Rebecca Pifer – Insulin pens are a commonly used tool for diabetic patients to control their blood sugar. About three-fifths of Americans with diabetes use the pens, which are normally dispensed in cartons of five, with each pen containing 300 mL of insulin. When pharmacies dispense insulin pens to patients in government programs like Medicare or Medicaid, they’re required to report certain data, like the quantity dispensed and how many days the supply will last. Read Full Article...

HVBA Article Summary

1. $38 Million Settlement Resolves DOJ and Whistleblower Allegations: CVS agreed to pay nearly $38 million to settle allegations that its pharmacies overcharged the government for insulin pens between 2010 and 2020. About $25 million of the settlement will go to the U.S. government, with the rest distributed to various states. CVS did not admit wrongdoing as part of the settlement.

2. Allegations of Systematic Overdispensing and Misreporting: According to the Department of Justice, CVS pharmacies were accused of prematurely refilling insulin, dispensing more than needed, and underreporting the actual quantity dispensed to bypass detection by pharmacy benefit managers (PBMs). These practices allegedly led to stockpiling of unused insulin by some patients.

3. CVS Cites Billing Complexity Amid Broader Legal Challenges: CVS attributed the issues to longstanding complexities in insulin pen billing, including dosing variability, packaging limitations, and plan supply restrictions. The company stated recent changes by PBMs and insurers have reduced these challenges. This case follows other major settlements in 2023, including $290 million and $949 million penalties related to overcharging and other pharmacy billing practices.

UnitedHealthcare drops prior authorization requirement for 231 procedures

By Allison Bell - UnitedHealthcare told providers earlier this week that it will no longer require them to get permission in advance to seek reimbursement for 231 procedures. "This change is part of our comprehensive effort to simplify the health care experience for our members and network health care professionals," UnitedHealthcare said in an announcement about its new prior authorization rules. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. UnitedHealthcare is Reducing Prior Authorization Requirements for Certain Procedures: UnitedHealthcare has announced it will eliminate prior authorization requirements for 231 medical procedures, including 196 nuclear medicine procedures, 18 obstetrical ultrasounds, and 17 electrocardiography procedures. This policy shift affects both employers that offer UnitedHealthcare commercial plans and individuals who purchase coverage through the Affordable Care Act exchanges. The change aims to streamline access to commonly needed diagnostic services.

2. Potential Benefits for Patients and Employers Seeking High-Value Care: By removing these prior authorization requirements, patients may face fewer delays in receiving essential and high-value medical care. Employers might view this as a positive step toward improving employee health outcomes and satisfaction. However, they still face ongoing challenges in managing health plan costs, particularly in curbing the use of unnecessary or low-value imaging services, which remain outside the scope of this change.

3. Policy Shift Reflects Growing Criticism of Prior Authorization Practices: This move comes amid increasing criticism from healthcare providers, patients, and policymakers, who argue that prior authorization processes are overly burdensome and inefficient. Providers often spend considerable time justifying clearly necessary procedures to insurance administrators. In response, UnitedHealthcare’s parent company, UnitedHealth, has committed to easing this burden as part of broader regulatory discussions, signaling a willingness to adapt to mounting pressure for reform.

HealthEdge survey: 85% of payer execs say regulatory pressures impacting margins

By Paige Minemyer - Health plans are feeling the pressure in a complex policy environment, with most executives polled in a new survey saying it's impacting costs and margins. HealthEdge released the results from its annual survey of health insurance executives, and 85% of the 550 polled leaders said the policy pressures are making themselves felt financially. This year's survey marks a "seismic" shift in the top concerns for payer execs, as, while cost management remains the No. 1 issue, fears about the regulatory environment have risen. Read Full Article…

HVBA Article Summary

1. Regulatory Pressures Have Surpassed Other Concerns: Regulatory concerns now top the list of payer priorities, overtaking member satisfaction and workforce issues, which were previously considered more pressing. This shift is largely due to the passage of the OBBBA, which has introduced real-time eligibility requirements, stricter accountability standards, and new demands for administrative transparency. These changes are exposing limitations in legacy systems that struggle to support real-time data exchange and compliance with evolving regulations.

2. Technology Investment is a Core Strategy: To address these regulatory and financial pressures, payers are increasingly turning to technology. This year’s survey shows a notable rise in focus on IT and business alignment. Furthermore, 60% of respondents said they are investing in artificial intelligence and advanced analytics to automate processes and manage costs. Additionally, 51% reported using AI or machine learning specifically to help avoid penalties related to interoperability requirements.

3. Digital Engagement and Member-Centric Tools are Growing Priorities: Payers are also prioritizing digital solutions aimed at improving the member experience. While 36% of organizations currently offer a member-facing chatbot, 50% of surveyed executives plan to roll one out within the next year. Other key areas of investment include virtual concierge and navigation services (44%), digital health assessments (43%), automatic claims adjudication to improve payment accuracy (39%), and greater personalization through data sharing and departmental integration (38%).

States ranked by average lowest-cost ACA gold premiums in 2026

By Jakob Emerson – Vermont will have the highest average monthly premiums for the lowest-cost Gold-tier marketplace plan in 2026, while Maryland will have the lowest, according to KFF. The national average is $615. Premiums were analyzed using the lowest-cost premium for a 40-year-old in each county and weighted by county plan selections. Read Full Article...

HVBA Article Summary

1. Significant variation in Gold‑tier premiums across states: The data reveal a substantial disparity in average lowest-cost Gold health insurance premiums, with Vermont topping the list at $1,135 per month and Maryland offering the lowest at $404. This wide gap — nearly triple — highlights how premium costs can differ dramatically based on location.

2. Geographic location is a major factor in insurance affordability: A person’s state of residence plays a crucial role in determining how much they pay for health insurance. Individuals in states like Maryland, New Hampshire, and Virginia generally benefit from significantly lower premiums compared to those living in high-cost states such as Vermont, New York, or Wyoming.

3. State-level premium differences affect overall access and affordability: Because the cheapest Gold-tier plans in high-premium states can still cost more than mid-tier or even higher-tier plans elsewhere, these price differences can influence both the affordability and the practical healthcare choices available to consumers depending on where they live.

Employee benefits understanding jumps to 80%, yet satisfaction hits a new low

By Alan Goforth – Workers are less satisfied with their benefits at the same time they say they are better informed about what their employer offers. More than 8 in 10 employees feel well informed about company benefits, up from three-quarters in 2024, a recent WTW survey found. However, only 6 in 10 feel satisfied with their benefit offerings, compared to two-thirds in the previous year. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Understanding Benefits Doesn’t Equal Effective Use: Despite a nearly $3 trillion annual investment by employers into benefit programs, many of these offerings remain underused and undervalued. According to a Nayya study, almost 75% of employees stick with the same benefits year after year, even after major life events like health diagnoses or income changes. Only 14% actively seek new benefit options annually. This suggests that while awareness may be rising, actual engagement and optimization of benefits remain low, highlighting a need for simplification and personalized guidance.

2. Balance Between Financial and Non-Financial Rewards is Crucial: Confidence in pay-for-performance alignment remains low, with only 41% of employees believing their pay aligns with their performance. In contrast, two-thirds (approximately 66%) report satisfaction with non-monetary benefits—an improvement from 61% in 2024. This growing appreciation for non-financial rewards indicates that employers who thoughtfully balance both financial and non-financial incentives can gain an edge in employee engagement, retention, and business outcomes.

3. Benefit Experience and Understanding Drive Satisfaction and Loyalty: A J.D. Power survey shows that satisfaction with commercial health plans varies considerably, with a national average score of 563 out of 1,000, ranging from 594 in the highest region to 523 in the lowest. Two in 10 employers say low employee satisfaction is a primary reason for switching health plans. Moreover, benefit comprehension plays a major role: among members who do not fully understand out-of-network coverage, nearly 50% experienced claim denials and 56% lacked access to preferred doctors. This underscores that education, communication, and personalized support are as critical as the benefits themselves.