Insurers face billions in underwriting losses

By Kristen Smithberg – Health insurers faced growing pressure in the Individual and Small Group markets in 2025 as medical costs rose faster than premiums, creating losses and prompting employers to reconsider how they offer health benefits. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Underwriting Losses in Core Markets: The Individual health insurance market posted a $5.5 billion underwriting loss in 2025, while the Small Group market reported a $507.5 million loss. These figures, based on data from the National Association of Insurance Commissioners’ Supplemental Health Care Exhibit, highlight the widening gap between claims costs and premium growth. The losses signal ongoing financial strain for insurers operating in these segments. They also reflect broader cost pressures affecting both carriers and plan sponsors.

2. Rising Claims Outpacing Premium Growth: In the Individual market, per-member, per-month medical claims rose 11.4%, increasing from $493 in 2024 to $549 in 2025. By comparison, average premiums grew just 3.1% to $577 per member per month. This imbalance contributed to enrollment dipping slightly to 21.3 million members. The data suggests that escalating health care expenses are not being fully offset by premium increases.

3. Small Employers Shifting Coverage Strategies: Small Group enrollment declined 7.9% in 2025 to 7.3 million members, and the market has lost more than 1.9 million members since 2022. Rather than eliminating benefits altogether, many small employers are exploring alternatives such as level-funded plans and Individual Coverage Health Reimbursement Arrangements (ICHRAs). In the Small Group market, claims expenses climbed 10% to $590 per member per month, while premiums increased 7.2% to $659. These trends indicate that employers are seeking more flexible and cost-controlled benefit models in response to sustained medical cost growth.

Evernorth unveils new AI-powered specialty pharmacy program, Pharmacy Forward

By Paige Minemyer – Evernorth has unveiled a new specialty pharmacy program that leans on AI to support a better experience for patients with complex conditions. Called Pharmacy Forward, the program aims to use technology to drive more coordinated, connected care and to offer personalized supports in real time. Evernorth plans to launch the program first for Accredo Specialty Pharmacy customers, investing $100 million through 2028 in the project. Read Full Article...

HVBA Article Summary

1. Significant Investment to Modernize Specialty Pharmacy: Evernorth is committing $100 million through 2028 to roll out Pharmacy Forward, beginning with customers of Accredo Specialty Pharmacy. The initiative is designed to integrate clinical data with AI-driven analytics to streamline operations and improve coordination. By prioritizing specialty pharmacy, the company is targeting patients with complex conditions who often require high-touch support. The phased approach suggests potential expansion into other pharmacy operations over time.

2. AI Aims to Improve Adherence and Reduce Administrative Burden: The company expects the platform to push medication adherence rates above the current industry benchmark of 80%. It also projects a 40% reduction in required clinical documentation, which could allow pharmacists and care teams to focus more on direct patient support. AI-enabled tools are designed to flag patients at risk of therapy interruptions or adverse events earlier in their care journey. Additionally, Accredo anticipates a 25% increase in the use of personalized digital patient pathways through the program.

3. Faster Access and Financial Impact: Evernorth says the technology will cut in half the time it takes patients to receive their prescriptions. AI will be used to improve prior authorization submissions and identify copayment assistance, potentially smoothing access to high-cost specialty drugs. The company estimates the initiative will generate $400 million in value by the end of 2028. Leaders at Evernorth and parent company Cigna describe the effort as part of a broader strategy to use real-time data and analytics to deliver more proactive, personalized care.

Federal dispute process driving up costs for planned procedures

By Michael Popke – While the patient protections put in place with the No Surprises Act are working, new research from the Elevance Health Public Policy Institute suggests that the law's payment dispute process is producing unexpected results for some planned medical procedures. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. IDR Usage Far Exceeds Expectations: The federal Independent Dispute Resolution process, established under the No Surprises Act in 2022, was intended as a limited backstop for payment disagreements. However, dispute volume has grown well beyond initial projections, raising concerns about how broadly it is being used. The Elevance Health Public Policy Institute analyzed more than 7,300 disputes involving typically scheduled procedures performed by out-of-network providers at in-network facilities. The findings suggest the mechanism is increasingly being applied to planned services rather than only unexpected emergency scenarios.

2. Providers Frequently Prevail and Receive Large Awards: According to the study, providers won 89.5% of disputed claim lines reviewed. The average IDR award for the procedures studied was nearly $40,000, while benchmark in-network or Medicare-based rates ranged from roughly $645 to $1,600. In addition, the median award through IDR was more than 50 times the median in-network contracted rate for the same service in the same market. These disparities indicate that arbitration outcomes are often significantly higher than typical contracted payment levels.

3. Rising Awards May Increase Employer and Family Costs: The research found that awards for the analyzed procedures increased 43% between 2024 and 2025, signaling a continuing upward trend. Elevance executives argue that when the dispute process is used beyond its original intent, it can contribute to higher overall healthcare spending. Because employers and families ultimately fund coverage through premiums and out-of-pocket costs, elevated arbitration awards may translate into broader financial impacts. The study’s authors suggest policymakers consider safeguards to ensure the process remains aligned with its patient-protection goals.

The post-subsidy ACA reality: What it means for benefits and the evolving broker role

By Chris Berggren – The Affordable Care Act (ACA) is entering a new phase. The expanded federal premium assistance that helped stabilize the individual insurance market over the past several years officially ended on December 31, 2025. Those enhanced subsidies, which were introduced during the pandemic and extended through 2025, had softened premium costs and expanded eligibility for millions of Americans. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Marketplace Instability Is Intensifying: With the return to the pre-2021 subsidy structure, households earning just over 400% of the federal poverty level once again face a subsidy cliff and may receive no financial assistance. At the same time, ACA benchmark premiums for 2026 have risen by roughly 20–25% nationally, with some regions experiencing even steeper increases. These higher costs are driven by medical inflation, pharmacy spending and expectations that healthier enrollees may exit the market. Together, these factors are contributing to renewed volatility in the individual insurance market.

2. Employers Are Feeling Operational and Financial Pressure: As individual coverage becomes less affordable, more employees—particularly part-time and seasonal workers—are turning back to employer-sponsored plans. This shift can alter employer risk pools, especially for small and mid-sized organizations, adding uncertainty to budgeting and plan design. Meanwhile, tighter affordability thresholds and higher penalties are raising the stakes for compliance errors. Employers in variable-hour industries such as hospitality, retail and logistics face some of the greatest strain.

3. Brokers Must Shift to Strategic Benefit Design: The article argues that brokers can no longer focus solely on plan renewals and pricing negotiations. Instead, they are positioned to guide employers toward alternative solutions such as minimum essential coverage (MEC), gap plans and short-term medical options tailored to workforce needs. Proactive education about subsidy changes and structured affordability assessments can help employers model compliance risks and identify vulnerable employee segments. Brokers who emphasize access, cost control and communication are likely to play a defining role in this next phase of ACA evolution.

How health insurance brokers can use AI to thrive

By Susan Rupe – Health insurance brokers have been using artificial intelligence for the past 30 years, but they didn't recognize it, one of the early developers of AI told members of the National Association of Benefits and Insurance Professionals at the organization's annual convention. Read Full Article...

HVBA Article Summary

1. AI Has Long Been Embedded in Insurance Workflows: The speaker emphasized that artificial intelligence is not new to health insurance brokers, even if it was not labeled as such. Tools such as rating engines, underwriting systems and claims processing platforms have incorporated AI-driven capabilities for decades. Everyday technologies like ZIP code readers and email filters illustrate how AI has quietly supported business processes. This perspective reframes AI as an evolution of existing systems rather than a sudden disruption.

2. Efficiency Gains Through Automation and Custom GPTs: Brokers are being encouraged to deploy AI to analyze their book of business daily, prioritize accounts and identify revenue opportunities automatically. By training custom GPT tools with their agency information, writing style and common client scenarios, brokers can automate email drafting and administrative follow-ups. AI can also capture voice notes, generate meeting summaries and integrate with customer relationship management systems. These uses aim to significantly reduce manual administrative work and free up time for client-facing activities.

3. Competitive Advantage Will Favor AI-Adopters: The presenter argued that AI will not eliminate brokers but will challenge traditional, manual operating models. Brokers who actively teach AI systems about their accounts, workflows and client needs are expected to gain a performance edge. Leveraging data to uncover coverage gaps and prioritize outreach could reshape how brokers manage top accounts. Over the next five years, success is expected to depend on how effectively brokers integrate AI into their daily business practices.

CMS launches the Medicare GLP-1 Bridge — but 4 questions linger

By Elizabeth Casolo – CMS is rolling out the Medicare GLP-1 Bridge program — a demonstration designed to give eligible Medicare Part D beneficiaries access to certain GLP-1s at a fixed monthly cost — July 1. CMS officials, including CMS Administrator Mehmet Oz, MD, broke down eligibility, pricing and prior authorization during a June press call. The program runs from July 1, 2026, through Dec. 31, 2027. Throughout the 18 months, CMS aims to gather data on how expanded GLP-1 access affects health outcomes, utilization and program operations. Read Full Article...

HVBA Article Summary

1. Program Structure and Cost Sharing: The demonstration sets a fixed monthly net price of $245 for participating GLP-1 drugs, with beneficiaries paying $50 and CMS covering the remaining $195. Manufacturers are supplying select medications, including Foundayo, Wegovy and Zepbound, under this arrangement. The agency has indicated there will be no impact on Part D premiums, and coupons or other discounts will not apply. Humana will act as the central processor even though the model operates outside the traditional Part D sponsor pathway.

2. Eligibility Rules and Coverage Limits: The Bridge program includes strict clinical criteria, such as minimum body mass index thresholds that vary based on comorbidities, and is focused on weight loss and maintenance. Individuals who already receive GLP-1 coverage through Part D for conditions like Type 2 diabetes are excluded. While clinicians may resubmit eligibility forms multiple times, there is no formal internal appeals process within the program. CMS has emphasized that the initiative is designed to avoid duplicating existing coverage.

3. Uncertainty Around Enrollment and Long-Term Future: CMS has not released official projections for enrollment or total program costs, though outside estimates suggest millions could qualify and early participation may reach the single-digit millions. The agency plans to use the 18-month window to evaluate health outcomes, utilization patterns and operational considerations before deciding next steps. Officials have not committed to reviving or replacing the paused BALANCE model and say future decisions will depend on data and ongoing negotiations with drugmakers. Congressional action on permanent Medicare coverage of weight-loss drugs remains a separate and unresolved issue.

How to solve client caregiving crises

By Chuck Greenblott – Your employer clients have a retention problem they don't know about yet. It's not compensation. It's not culture. It's not competitors poaching their best people. It's a 48-year-old project manager running on four hours of sleep because her mother fell again last night, quietly researching assisted-living facilities on her phone under her office desk. She's one bad week from resigning. Her exit interview will say "personal reasons." Nobody will connect the dots. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Caregiving Is a Widespread, Underrecognized Workforce Strain: The article argues that caregiving responsibilities are already embedded in nearly every workforce, yet many employers fail to acknowledge their scale. It notes that 53 million Americans provide unpaid care to family members, and most of them are employed. Because employees often keep these pressures private, leaders may underestimate the retention risks tied to burnout. This disconnect allows preventable turnover to continue under the label of “personal reasons.”

2. Current Benefits Offerings Often Miss the Mark: Many organizations rely on employee assistance hotlines, limited backup care and leave policies that employees feel discouraged from using. The author contends that these measures are frequently underutilized because workplace culture signals that visible need could harm career prospects. As a result, high-performing mid-career employees may quietly absorb mounting stress until they resign. The gap between formal policy and what workers believe is safe to use becomes a hidden driver of attrition.

3. Demographic and Economic Pressures Will Intensify the Crisis: Rising child care and home health costs, potential Medicaid cuts and the aging of 70-plus million Baby Boomers are expected to compound caregiving burdens. By 2030, every Baby Boomer will be over age 65, and long-term care needs are projected to nearly double. The author suggests employers should move beyond point solutions and invest in cultural change, manager training and navigation support with real human assistance. Organizations that act early may gain a competitive retention advantage as the “sandwich generation” becomes a dominant share of the workforce.

Food Noise: a Real Phenomenon Deserving of Being Treated

By Marilynn Larkin – “Food noise” is experiencing a huge research moment. Patients have been talking about the phenomenon for the past few years, especially on social media. The realization that GLP-1 drugs seemed to dampen the impact of this unwanted preoccupation with food, or even make it disappear entirely, has caught researchers’ interest and has spurred a plethora of new studies, three definitions and related clinical tools, as well as hypotheses about the mechanisms underlying the phenomenon. Read Full Article...

HVBA Article Summary

1. Emerging Definitions and Measurement Tools: Researchers have not yet settled on a single definition of food noise, but three recently proposed frameworks share an emphasis on persistent, intrusive food-related thoughts. Tools such as the five-item Food Noise Questionnaire (FNQ) and the RAID-FN Inventory in seven- and 23-item formats aim to quantify severity and dimensions like preoccupation and dysphoria. Validation studies in adults with obesity show that higher scores correlate with a greater tendency to overeat. These instruments are intended to legitimize patient experiences and help clinicians track treatment response.

2. GLP-1s and Treatment Effects: Observational data presented at the European Congress on Obesity 2026 found that patients starting a GLP-1 alongside behavioral therapy had larger short-term reductions in food noise scores than those receiving behavioral therapy alone, with an adjusted mean change of -4.1 vs -1.2 points after 1 month. Experts hypothesize that GLP-1 receptor activity in the brain may dampen food cue reactivity, helping quiet intrusive thoughts. Reports also suggest food noise may return after discontinuing medication, consistent with the drug’s mechanism of action. Bariatric surgery patients have described similar but generally less dramatic changes.

3. Possible Mechanisms and Clinical Implications: Some researchers link food noise to semi-starvation and repeated dieting, drawing parallels to findings from the Minnesota Starvation Experiments and noting associations between food noise scores and frequent dieting. Others are exploring neurologic explanations involving dysregulation of inhibitory control in the brain. Clinicians are encouraged to distinguish physiological hunger from intrusive rumination, assess triggers such as stress and sleep deprivation, and consider interdisciplinary care. Incorporating validated food noise measures into trials and practice may allow more tailored treatment strategies in the future.