NCQA forms AI working group for health plan, provider use of high-risk AI

By Emma Beavins – The National Committee on Quality Assurance (NCQA) has launched an artificial intelligence working group to determine how to best measure performance of high-risk AI once it has been deployed by health plans and providers. The 35-year-old organization runs a spate of quality measurement and reporting programs, like health plan accreditation and the Healthcare Effectiveness Data and Information Set (HEDIS) measures used by 90% of health plans, according to the Office of the Assistant Secretary for Planning and Evaluation. Read Full Article...

HVBA Article Summary

1. Collaborative AI Governance in Healthcare: The National Committee for Quality Assurance (NCQA) has assembled a diverse coalition of over 30 healthcare organizations—including insurers, provider groups, and public health entities—to participate in a dedicated AI working group. This initiative is designed to foster collaboration, promote knowledge-sharing, and guide the creation of practical standards for the responsible use of AI technologies within healthcare delivery systems.

2. Focus on Post-Deployment Monitoring and High-Risk Use Cases: The working group is specifically focused on the oversight of AI systems after they have been deployed by health plans and providers. Emphasis is placed on identifying and defining high-risk use cases, such as complex AI-assisted systems that involve multiple interacting models. These scenarios pose unique challenges for performance evaluation and patient safety, prompting the group to explore risk-based governance strategies tailored to various AI applications.

3. Goal to Develop Practical Resources for Health Plans and Providers: Rather than engaging in AI model development or vendor-specific processes, the NCQA’s objective is to support healthcare organizations in managing and monitoring AI in real-world settings. The group aims to produce actionable resources—such as policy guidance, transparency frameworks, performance metrics, or an AI implementation playbook—based on shared experiences and common challenges identified through ongoing monthly convenings.

Looming ACA changes could push 400K workers toward 'unaffordable' employer coverage

By Allison Bell – The federal government could soon saddle employers with a new health benefits administration problem: 400,000 workers who no longer can get as much government help with paying for Affordable Care Act public exchange coverage but who officially earn too little to pay for their employers' health coverage. Phillip Swagel, director of the Congressional Budget Office, mentioned the concern Monday in a summary of CBO predictions about how new ACA regulations and the expiration of temporary premium subsidy increases will affect Americans' access to health coverage. A federal judge in Maryland, U.S. District Judge Brendan Hurson, issued a ruling Friday that temporarily pauses implementation of most of the regulations. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Potential coverage gap of 400,000 workers: The CBO estimates about 400,000 people could lose access to generous ACA exchange subsidies yet still be classified as too low-income to afford employer coverage, creating a coverage affordability problem for employers and workers. This change stems from the expiration of temporary premium subsidy increases enacted during the COVID emergency response. If implemented, affected workers could face higher premium shares or difficulty affording employer-sponsored plans.

2. CBO estimates and legal developments point to broader impacts: The CBO memo cited by Phillip Swagel estimates that 1.8 million people could lose coverage if the regulations proceed and current premium subsidy levels expire, and about 400,000 of those would have access to employer coverage that is considered unaffordable under federal rules. A federal judge in Maryland has temporarily paused implementation of most of the regulations, which could alter those projected outcomes. The CBO also noted that some employers with more than 50 employees may face penalties if too many workers' required premium shares exceed government affordability thresholds.

3. Market integrity regulations aim to tighten eligibility and enrollment but may change access dynamics: HHS' market integrity rules would require exchanges to do more verification of applicants' eligibility and would require enrollees to pay at least $5 per month to help ensure they notice unauthorized enrollments. The regulations are intended to address problems such as misreported income, incorrect addresses, or enrollment fraud. Together with subsidy expirations, these verification changes could shift who qualifies for exchange subsidies and how enrollment issues are identified and resolved.

DOJ's criminal probe into UnitedHealth extends to Optum Rx, physician reimbursement: report

By Paige Minemyer – The Department of Justice's ongoing criminal investigation into UnitedHealth Group extends beyond Medicare Advantage, according to a new media report. Bloomberg cited individuals with knowledge of the matter who said that DOJ is also probing billing practices at Optum Rx and how UnitedHealth reimburses its own physicians. Read Full Article...

HVBA Article Summary

1. Ongoing Federal Investigations into UnitedHealth: UnitedHealth Group has formally acknowledged a federal investigation into its Medicare Advantage practices, including both criminal and civil probes. These investigations are being led by the Department of Justice and involve interviews with former employees. Allegations center around the possible inflation of patient diagnoses that may have led to overpayments. There are no formal charges or confirmed allegations at this time.

2. Company’s Response and Compliance Measures: UnitedHealth has stated it is cooperating fully with the DOJ, proactively contacted authorities, and is complying with formal requests. The company also mentioned ongoing third-party reviews to ensure compliance, and cited independent audits that support the accuracy of its practices. It continues to assert its longstanding record of responsible conduct and regulatory adherence.

3. Market Impact and Investor Attention: While no formal accusations have been made, news of the investigation has led to minor stock dips for UnitedHealth Group. Investor concerns may grow as the scope of the investigation expands. Additional scrutiny is also arising from a separate DOJ antitrust probe related to the company’s internal operations between UnitedHealthcare and Optum.

Over 97M Americans now lack commercial coverage for Zepbound

By Alan Goforth – Despite continued growth in the popularity of GLP-1 weight-loss drugs such as Zepbound and Wegovy, commercial insurance coverage often is becoming more restrictive. “The number of people with no commercial insurance coverage for Zepbound increased by over 180% in 2025, leaving over 97 million people with no coverage,” a new study from GoodRx found. “For those who have insurance coverage, over 90% still have to meet additional requirements like prior authorization.” Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Zepbound Coverage Decline: CVS Caremark removed Zepbound from its standard formulary in July 2025, leading to a substantial drop in insurance coverage. Unrestricted coverage fell from 9% to 5%, and restricted coverage dropped from 73% to 45%. As a result, the percentage of people with no coverage for Zepbound rose dramatically from 18% to 51%, affecting over 97 million individuals.

2. Wegovy Access Slightly Improved: Although unrestricted coverage for Wegovy declined from 14% to 10% in 2025, restricted coverage increased from 67% to 75%, largely due to CVS Caremark placing Wegovy on its preferred formulary. This change led to over 6 million people gaining some level of insurance coverage for the drug. However, more than 28 million people still lack commercial coverage for Wegovy.

3. Mixed Trends for Other GLP-1 Drugs: Coverage remained relatively stable for Ozempic and improved slightly for Mounjaro, with over 1.8 million people gaining access. Despite this, around 660,000 people still lack coverage for Mounjaro, and nearly 5 million remain without coverage for Ozempic. The introduction of generic liraglutide improved access for that formulation but worsened coverage for branded versions, Victoza and Saxenda, with 41 million and 16 million people losing coverage respectively. In total, about 19 million commercially insured individuals lack coverage for any GLP-1/GIP medications prescribed for weight loss in 2025.

9 payers recently fined by states

By Jakob Emerson – Payers have faced state penalties in 2025 for slow reimbursements, improper claims denials, and mental health parity violations. Fines in 2024 are here. Read Full Article...

HVBA Article Summary

1. Widespread Mental Health Parity and Directory Violations: Several insurers, including MVP Health Plan, Premera Blue Cross, Cigna, and Anthem Blue Cross of California, were fined for failing to comply with mental health parity laws and for providing inaccurate or outdated provider directory information. These issues reflect ongoing industry-wide challenges in meeting regulatory requirements for behavioral health services and provider access transparency.

2. COVID-19 Cost-Sharing Compliance Failures: UnitedHealthcare, BCBS Rhode Island, and Aetna were penalized for improperly applying cost-sharing to COVID-19-related services, specifically failing to waive out-of-network costs as required. These fines highlight regulatory enforcement around pandemic-era protections and insurer obligations to provide accessible care during public health emergencies.

3. Administrative and Claims Processing Deficiencies: Insurers such as Anthem, Blue Shield of California, Centene, and UnitedHealthcare faced fines for failures in appeals handling, timely service approvals, and accurate claims processing. In particular, Anthem was penalized multiple times for unresolved appeals and delays, while Blue Shield and Centene were cited for processing errors and appointment access issues, respectively. These actions underscore regulatory focus on member impact due to administrative shortcomings.

Engaging employer clients year-round: content marketing strategies for benefits advisors

By Andrew Metz – It was Bill Gates who coined the phrase "content is king" as far back as 1996, when he predicted that the internet would take over everything from news to entertainment and marketing. But he also said information in this new era of communication must be “deep and extremely up to date” and that people “need an opportunity for personal involvement.” This is advice that benefits advisors would do well to bear in mind, as one of the best ways to support clients is to communicate with them regularly and with meaningful and useful information. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Regular, meaningful content strengthens client relationships:: Advisors who communicate consistently with useful information can deepen and extend client relationships. Many advisors currently touch base only at renewal time, which misses opportunities to add value throughout the year. Building a steady stream of high-quality content can position advisors as trusted partners.

2. Three practical challenges and solutions for advisors:: The article identifies three main hurdles—creating content, centralizing storage, and distributing it to clients—and recommends outsourcing content creation when in-house capacity is limited. It cautions that AI-generated content can be useful but requires careful curation to avoid dated or inauthentic output. A centralized content management system is advised to ensure team access and version control.

3. Measure and repurpose content across channels:: Success should be tracked using website analytics, social metrics, and email click data to learn what topics and formats engage clients. Repurposing the same content as blog posts, social snippets, video, or webinars can extend reach and meet clients where they consume information. A defined content strategy that identifies audience, goals, and tone will help advisors prioritize platforms and measure ROI.

Lilly pill cuts body weight by 10.5% in patients with type 2 diabetes

By Patrick Wingrove – Eli Lilly (LLY.N), said on Tuesday its experimental GLP-1 pill helped overweight adults with type 2 diabetes shed 10.5% of body weight in a late-stage trial, after recent data from another study of the drug in patients without diabetes sent company shares tumbling. Shares of the drugmaker rose nearly 4% to $722 in early trading. Read Full Article...

HVBA Article Summary

1. Effective Blood Sugar and Weight Management in Diabetic Patients: In a 72-week trial involving over 1,600 overweight or obese adults with type 2 diabetes, Lilly’s once-daily pill orforglipron met its primary goal. The highest dose led to a 10.5% average weight loss (~23 pounds) and helped 75% of patients lower their A1C levels to ≤6.5%, below the American Diabetes Association’s 7% target.

2. Commercial and Competitive Potential: Analysts noted that the trial data aligned with expectations, supporting the case for orforglipron’s U.S. marketing approval. The drug's oral format offers manufacturing and distribution advantages over injectable GLP-1-based treatments like Wegovy and Zepbound. Forecasts suggest peak global sales of $14.7 billion, with the drug positioned as a competitive alternative, especially for patients resistant to injectables.

3. Side Effects and Regulatory Outlook: The most common side effects were gastrointestinal, with 36.4% of high-dose patients experiencing nausea and 23.1% vomiting; over 10% discontinued due to side effects. However, no liver safety concerns were reported, and improvements in cardiovascular risk markers were noted. Lilly now has a full clinical package and is exploring expedited FDA review options for regulatory approval.