Aetna, Anthem parents face House Judiciary probe over ACA fraud

By Allison Bell – The House Judiciary Committee is grilling the major issuers of Affordable Care Act public exchange plans over their participation in the program. The committee announced Tuesday that it's asking the health insurers about their efforts to verify the applications of people get exchange plan coverage and federal health insurance premium subsidies. The committee sent the subpoenas to Elevance Health, which is the parent of Anthem Blue Cross, and to CVS Health, which is the parent of Aenta. The committee also sent subpoenas to Blue Shield of California, Centene, GuideWell, Health Care Service Corp., Kaiser Permanente and Oscar Health. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Congressional Scrutiny of ACA Insurers: The House Judiciary Committee has issued subpoenas to several major health insurers, including the parent companies of Aetna and Anthem, to investigate their processes for verifying eligibility for ACA exchange plan subsidies. This move signals heightened congressional concern about potential fraud in the administration of federal health insurance premium subsidies. The investigation could lead to increased regulatory oversight or changes in how insurers are required to verify applicant eligibility.

2. Potential Impacts Beyond Individual Plans: While the subpoenas are focused on ACA exchange plans, there is a possibility that the inquiry could touch on employer-related health arrangements, such as individual coverage health reimbursement arrangements (ICHRAs) and qualified small employer HRAs (QSEHRAs). Even if these topics are not directly addressed, the investigation may indirectly affect employer plan sponsors by influencing insurers' willingness to participate in certain markets. Insurers have already indicated a shift toward a more selective approach in offering fully insured major medical coverage.

3. Debate Over Fraud Prevention and Regulatory Reform: The committee's interest is partly driven by a recent court decision that blocked the Trump administration's attempt to impose stricter eligibility verification requirements, citing procedural concerns under the Administrative Procedures Act (APA). Lawmakers are now considering whether reforms to the APA are necessary to allow for faster implementation of healthcare fraud prevention measures. The outcome of this investigation could shape future legislative efforts aimed at balancing fraud prevention with regulatory safeguards.

Copay Accumulators and Maximizers in 2025: Popular, Profitable, and Problematic

By Adam J. Fein, Ph.D. – Valentine’s Day is almost here! It’s the perfect time for our annual update on plan sponsors’ enduring sweetheart: copay accumulators and maximizers—the benefit designs that divert manufacturers’ copay support away from patients and toward plans and PBMs. As of late 2025, about four in ten commercially insured lives were enrolled in plans using a copay accumulator or a maximizer. Patients who rely on single-source, brand-name specialty drugs for autoimmune conditions, multiple sclerosis, and oncology are increasingly likely to encounter these designs. The data below illustrate how widespread these programs have become—and where their impact is most acute. Read Full Article...

HVBA Article Summary

1. Widespread Adoption and Growth: Copay accumulators and maximizers have become increasingly prevalent in commercial insurance plans, with a significant rise in their adoption since 2020. While the majority of plans now include these features in their design, not all have fully implemented them for all beneficiaries. This trend reflects a growing focus by plan sponsors and PBMs on capturing manufacturer copay assistance to offset their own costs.

2. Patient Impact and Health Equity Concerns: These benefit designs most heavily affect patients who require expensive specialty medications, often resulting in higher out-of-pocket costs and unexpected financial burdens. Research indicates that accumulators can reduce medication adherence and disproportionately impact non-white and lower-income patients, raising concerns about health equity. State-level bans on accumulators have been shown to lower patient costs and improve adherence, but such protections are not universal.

3. Regulatory and Profitability Dynamics: While more states are enacting laws to restrict copay accumulators, these laws typically do not apply to self-insured plans, leaving many patients unprotected. The federal regulatory environment remains uncertain, with no clear guidance on the future of these programs. Meanwhile, maximizer programs can generate substantial profits for PBMs and their partners, sometimes at the expense of transparency and patient affordability.

House Republicans subpoena 8 insurers over ACA fraud protection measures

By Dave Muoio – Republicans on the House Judiciary Committee have subpoenaed eight insurers for documents outlining their measures to head off fraud related to Affordable Care Act subsidies. The information demands follow an attempt from the Trump administration over the summer to enact new guardrails on improper enrollments, which was paused by the courts amid ongoing litigation. The Republican committee heads said their inquiries could help unstuck that regulatory effort. Concerns over incentivizing enrollment fraud have been central to Republicans’ argument against extending the advanced premium tax credits (APTC) that expired at the end of last year. Read Full Article...

HVBA Article Summary

1. Congressional Oversight Intensifies: The House Judiciary Committee's decision to issue subpoenas to eight major insurers marks an escalation in congressional oversight regarding ACA subsidy fraud. Lawmakers had previously requested this information voluntarily, but varying levels of compliance prompted the formal legal action. The committee aims to use the gathered data to inform potential legislative reforms, particularly concerning the Administrative Procedure Act.

2. Regulatory Efforts and Legal Challenges: Attempts by the Trump administration to implement stricter controls on ACA enrollments were halted by a court injunction, with several provisions challenged under the Administrative Procedure Act. The proposed regulations included eliminating certain special enrollment periods, adjusting plan tier calculations, and introducing penalties for improper enrollments. Ongoing litigation and appeals have left these regulatory changes in limbo, with lawmakers seeking more information to guide future policy.

3. GAO Findings Highlight Fraud Risks: Recent reports from the Government Accountability Office revealed significant vulnerabilities in the ACA enrollment process, including unauthorized broker or agent changes and multiple uses of identification numbers for coverage. The GAO also documented hundreds of thousands of consumer complaints about unauthorized enrollments or coverage adjustments. These findings underscore concerns about federal spending waste and potential harm to consumers, such as unexpected costs or loss of access to medical care.

US FDA Says Novo's Obesity Pill TV Ad Is False or Misleading

By Sriparna Roy – The U.S. Food and Drug Administration said a television advertisement for Novo Nordisk's weight-loss pill is "false ‌or misleading," according to a letter dated February 5. The health regulator said the television spot misleadingly suggests that ⁠Wegovy, in its pill form, offers an advancement or improvement over other weight-loss drugs that ‌belong to the class known as GLP-1s. Read Full Article...

HVBA Article Summary

1. FDA Criticism of Advertising Claims: The FDA determined that Novo Nordisk's television advertisement for its weight-loss pill, Wegovy, was misleading. The agency stated that the ad implied the pill was superior to other GLP-1 class weight-loss drugs, despite no evidence supporting this claim. As a result, the FDA requested that Novo Nordisk take immediate corrective action regarding the advertisement.

2. Implications of Misleading Messaging: The FDA highlighted that phrases such as "live lighter" and "a way forward" in the ad could give viewers the impression that Wegovy offers greater weight loss or additional benefits compared to other approved treatments. The agency also noted that the ad suggested benefits beyond physical weight loss, such as emotional relief or improved life direction, which have not been demonstrated. Such messaging could mislead consumers about the scope and effectiveness of the medication.

3. Company Response and Regulatory Oversight: Novo Nordisk acknowledged receipt of the FDA's letter and stated it is working to address the agency's concerns. The company emphasized its commitment to regulatory compliance and indicated it is reviewing the advertisement's presentation. This incident underscores the importance of accurate marketing in the pharmaceutical industry and the FDA's role in monitoring drug promotion to protect consumers.

Cigna to cut 2,000 jobs

By Jakob Emerson – The Cigna Group is cutting approximately 2,000 jobs globally by the end of February, representing less than 3% of its workforce. “As we drive greater efficiency across our business, we have made the difficult decision to reduce roles in our workforce,” a spokesperson for The Cigna Group told Becker’s. “This decision was made with deliberate care and focus, and we are providing a package that includes a variety of transition services for impacted colleagues.” Read Full Article...

HVBA Article Summary

1. Layoffs and Uncertainty: Cigna has initiated workforce reductions, but the full extent remains unclear, with no specific information provided about which departments, job functions, or geographic regions are most affected. Notably, no WARN Act filings have been made in Connecticut, where Cigna is headquartered, suggesting that either the layoffs were below the reporting threshold or are still unfolding.

2. Regulatory and Operational Developments: The timing of the layoffs closely follows a significant regulatory development involving Express Scripts, Cigna’s pharmacy benefit manager. On February 4, the FTC announced a settlement requiring the PBM to address allegations of insulin price inflation by restructuring how it compensates drug manufacturers, increasing access to low-cost options like TrumpRx, and relocating its group purchasing organization operations from Switzerland back to the U.S.

3. Financial and Membership Changes: Despite Cigna posting nearly $6 billion in profits for 2025 and projecting an ambitious $280 billion in revenue for 2026, the company experienced a 5% year-over-year decline in total medical membership. This drop was primarily due to the divestiture of its Medicare business to Health Care Service Corporation, reflecting a potential strategic realignment away from certain government-sponsored healthcare segments.

Why now is the best time to re-engage employers

By Lindsey Kratzer – Open enrollment may be over, but for benefit brokers and advisers this is when the real work — and real opportunity — begin. In conversations across our national network of senior executives at benefits brokerage and consulting firms, we're hearing a consistent theme: this is the window when smart brokers turn lessons from open enrollment into strategy for the year ahead and align with vendors to make it happen. The best brokers use this time to meet with employer clients, unpack what resonated with their populations, what confused employees and what needs to evolve before next year's open enrollment. Those who do it well turn post-enrollment insights into lasting value for employers and set the pace for the year ahead. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Post-Enrollment Period as a Strategic Opportunity: The time immediately following open enrollment is crucial for brokers and advisers to reflect on what worked and what did not. Engaging with employers during this period allows for the identification of areas needing improvement and the development of strategies for the coming year. This proactive approach can turn short-term feedback into long-term value for both employers and employees.

2. Cost Control and Employee Well-Being Remain Central Challenges: Employers are increasingly focused on managing benefit costs, while employees are struggling with rising healthcare expenses and financial stress. Innovative solutions such as alternative funding models and financial wellness benefits are gaining traction as ways to address these dual pressures. Brokers who can connect these solutions to measurable business outcomes are better positioned to differentiate themselves in the market.

3. Collaboration and Data-Driven Insights Drive Success: Successful brokers use the post-enrollment window to gather feedback from both employers and vendors, analyze early data, and identify communication gaps. By leveraging these insights in early strategic planning sessions, brokers can help shape benefit strategies that are responsive to client needs and evolving market trends. This collaborative, data-informed approach helps set the pace for the upcoming year and strengthens broker-client relationships.

Humana could end 2026 as the largest Medicare Advantage insurer

By Rebecca Pifer Parduhn – Humana expects to grow its Medicare Advantage membership by more than 25% this year, a prediction that could lead the insurer to supplant UnitedHealthcare as the largest MA carrier in the U.S. — while potentially saddling Humana with higher medical spending. Humana added roughly 1 million individual MA members during the sign-up period for 2026, and expects that momentum to continue over the year, executives told investors during a Wednesday morning call to discuss the company’s fourth quarter results. Read Full Article...

HVBA Article Summary

1. Humana's Growth Could Shift Medicare Advantage Leadership: Humana's expectation to increase its Medicare Advantage membership by over 25% in 2026 could position it as the largest MA insurer in the U.S., potentially overtaking UnitedHealthcare. This growth is driven by adding about 1 million new members during the recent sign-up period and maintaining momentum throughout the year. However, this expansion comes with risks related to increased medical spending and cost pressures in the MA market.

2. Financial Challenges Amid Rapid Enrollment: Despite the membership growth, Humana reported a significant loss of $796 million in the fourth quarter, attributed to unexpectedly high medical spending and a high medical loss ratio (MLR) of 93.1%. The insurer's 2026 earnings guidance is lower than analyst expectations, partly due to declining MA star ratings affecting quality bonus payments. Rising costs for hospital services and drugs, combined with reimbursement rates not keeping pace, contribute to financial pressures.

3. Strategic Expansion Beyond Medicare Advantage: In addition to its MA business, Humana is expanding its Medicaid division and primary care services through its CenterWell brand, planning to add 60 to 70 new locations in 2026. The company is also exploring mergers and acquisitions in the primary care space to support growth. This diversification may help Humana mitigate some risks associated with the challenges in the Medicare Advantage market.