29 pages; updated Jan. 23, 2026. "The 2025 benefit year risk adjustment models use the Version 08 (V08) HHS-hierarchical condition category (HCC) classification, first implemented in the 2025 benefit year, and include interaction variables based on HCC count factors, first implemented in the 2023 benefit year.... In addition to classification changes, the 2025 benefit year risk adjustment models are recalibrated using blended coefficients from the 2019, 2020, and 2021 enrollee-level External Data Gathering Environment (EDGE) data. T" [Also available: Technical Details (XLSX) and 2025 Benefit Year Risk Adjustment: SAS Version of HHS-Developed Risk Adjustment Model Algorithm Software (ZIP)]   MORE >>

"Those responsible for calculating QPAs on behalf of group health plans and insurers will need to take note of this guidance as they implement these complex rules for 2026. The table of cumulative percentages provided in [Notice 2025-65] may help simplify the calculations"  MORE >>

"For 2025 returns and statements filed and furnished in 2026, the penalty for failing to file electronically (or otherwise failing to file correctly) is increased to $340 per return, not to exceed $4,098,500 ... Failures corrected within 30 days result in reduced penalties of $60 per return or statement, not to exceed $683,000 ... Failures corrected by August 1 result in reduced penalties of $130 per return or statement[.]"  MORE >>

"In 2025, a total of 26 states enacted legislation regulating pharmacy benefit managers (PBMs). Although the content of the legislation varies among states, there is a consensus to increase transparency and lower prescription drug costs. This article explains current state legislative trends affecting PBMs."  MORE >>

"As many Minnesotan employers are quickly discovering, the post-PFML workplace poses significant operational challenges. As the legal landscape continues to evolve in Minnesota (and those benefit applications keep rolling in), employers must become intimately familiar not only with administering the program but also with the variety of pitfalls it creates."  MORE >>

"Colorado HFWA leave must be paid at the same pay rate, with the same benefits, the employee would have been afforded had they worked during the leave period. Employees will not earn additional compensation during HFWA leave if the use of leave does not reduce their pay. For employees paid wages plus commissions, the calculation of the HFWA pay rate does not include commissions.... The 'lookback period' for calculating the HFWA pay rate applies only when the pay rate for the leave period is unknown."  MORE >>

"Applying arbitrary-and-capricious review, the Sixth Circuit emphasized that ERISA requires reasoned decisionmaking, which has both procedural and substantive components. The court focused on procedural deficiencies and concluded that Anthem's decision failed at that threshold level.... The plaintiff alleged that Anthem mishandled mental health claims more restrictively than medical or surgical claims but failed to identify record evidence demonstrating how Anthem applied treatment limitations to medical or surgical benefits in practice." [T.E. v. Anthem Blue Cross & Blue Shield, No. 25-5407 (6th Cir. Jan. 22, 2026)]  MORE >>

"Plaintiff's counsel -- primarily based in California -- sought rates ranging from $500 to $900 per hour. United argued that Texas rates should apply and that the requested rates were excessive. The court rejected those arguments, finding that the plaintiff had demonstrated the necessity of retaining out-of-district counsel with specialized experience in ERISA mental health and eating-disorder claims." [Dwyer v. UnitedHealthcare Insurance Co., No. 17-0439 (W.D. Tex. Jan. 21, 2026)]  MORE >>

"In most cases, plans will follow an approach that tracks the NAIC model coordination of benefit rules -- either pursuant to state insurance requirements or plan terms designed to mirror those model rules -- to determine which plan is primary and which is secondary. Where governmental programs such as Medicare, Medicaid, TRICARE, or VA services are involved, special coordination rules apply."  MORE >>

"Twenty percent of individuals with employment-based health benefits accounted for roughly 84 percent of overall spending, and 80 percent of the population accounted for only 16 percent of spending.... Overall, 50 percent of the population used no or next to no health care in 2023."  MORE >>

"The Wegovy pill does not create a new decision for employers. It reinforces the importance of having a clear and consistent GLP-1 strategy.... The Wegovy pill uses the same underlying medication at higher doses and is approved specifically for weight management. While the formulation is similar, the approved use, dosing, and coverage considerations are different."  MORE >>

"Adherence with GLP-1 therapy differs for diabetics and those using the medication for weight loss. Adherence also differs among age groups and between men and women. Adherence rates have a significant impact on savings."  MORE >>

"VBP adoption has ... been significant, now comprising half of traditional Medicare. Through risk contracting and vertical consolidation, VBP is a defining feature of Medicare Advantage (MA) and embraced by its biggest payers, UnitedHealth Group and Humana. But ... VBP is failing to bend the cost curve, encouraging consolidation and corporate intermediaries, and diverting policy makers away from the true cost drivers."  MORE >>