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Twice-Weekly Briefing
Friday, September 18, 2026
Issue 260918-64
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
Five developments, and what each one costs you.
| 1. | A public plan sponsor put five artificial intelligence limits on the carriers that administer its health plans. | | 2. | Providers won 86.4 percent of disputed surprise billing line items in 2025, at a median of 3.9 times the plan's benchmark rate. | | 3. | Consumer medical inflation ran 1.6 percent over the year, nowhere near your renewal quote. | | 4. | Eight new appointments to the panel whose ratings set which preventive services your plan covers with no cost sharing. | | 5. | Half of employer plan members with multiple conditions say their insurer denied or delayed prescribed care within two years. |
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| 1 · HEALTH PLAN AI · September 16, 2026 |
| Connecticut Told Its Carriers That AI Alone Cannot Deny a Claim for 270,000 Plan Members |
| Connecticut Comptroller Sean Scanlon announced on September 16, 2026 five artificial intelligence protections covering the carriers that administer the State Employee Health Plan and the Partnership Plan, which the announcement puts at more than 270,000 members. The first reads, "No adverse determination may be made solely by an AI system, and they must always be reviewed by a human." The second says carriers "cannot use AI or predictive models as the sole basis to downcode claims, reduce provider payments, or alter billing codes without human review," while "Authorized contractual and automated claims processes remain permitted." The third says member data "cannot be used to train, develop or support other AI models." The fourth requires carriers and providers to "disclose when AI is materially assisting with, directly interacting, or recommending a benefit or health service to a member," and the fifth says AI systems must be "validated against historical data for accuracy, consistency, and fairness," with carriers disclosing their governance and audit procedures to the Comptroller. The announcement says Scanlon will work with the legislature to extend the policy to all state-regulated insurance plans in the 2027 session. This is a purchaser setting terms for its own plans rather than a regulation, and the announcement names no effective date and no penalty. |
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MOC Perspective
Another plan sponsor did your homework and published it. Connecticut did not wait for a statute; it wrote what it wanted into what it buys, and you can put the same language in your administrative services agreement at renewal. The clause most plans are missing is the third one, because almost no agreement says anything about whether your members' claims data may train a vendor's model. Ask for all five in writing and treat silence as a no.
What to do now
| ▪ | Pull your administrative services agreement and check all five Connecticut protections against it before your 2027 renewal signs. | | ▪ | Ask your administrator in writing whether member claims data trains any AI model, and set a 30 day deadline for the reply. | | ▪ | Add a human review requirement for adverse determinations and for downcoding to your next contract, effective January 1. |
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| Source: Connecticut Office of the State Comptroller |
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| 2 · OUT-OF-NETWORK DISPUTES · September 14, 2026 |
| Providers Won 86.4 Percent of Disputed Line Items in 2025, at a Median 3.9 Times the Benchmark |
| The Paragon Health Institute published an analysis of the No Surprises Act arbitration system on September 14, 2026, written by Jackson Hammond and Katherine Hall from the CMS federal independent dispute resolution public use files and CMS supplemental reports. Total dispute initiations reached 2.56 million in 2025, which the report calls 115 times the government's initial projection. For comparison, initiations from April to December 2022 ran nine times the projection for that whole year. Providers prevailed in 86.4 percent of all disputed line items when default decisions are included, up from 78.1 percent in 2023, and in 85.2 percent when defaults are excluded. The median award was 3.9 times the qualifying payment amount and the mean was 7.6 times it, with the median running about 5.5 times the Medicare rate for the same service. Arbitrator fees for emergency and non-emergency disputes averaged around $596 in 2025, up from $482 in 2023, and the losing party pays them. For the cost of all this the report cites the Center on Health Insurance Reforms rather than its own analysis, at an estimated $16.6 billion in 2025. Paragon argues that Congress should scale the process back, so its recommendations are argument and not finding. |
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MOC Perspective
The No Surprises Act reaches self-funded plans, because ERISA preemption had kept state surprise billing laws away from them and the federal law closed that gap. A share of those 2.56 million initiations ends in an award that sets a price your plan may pay, and nobody from your side was in the room. Your point of control is the qualifying payment amount your administrator calculates and the network gaps that push claims into arbitration in the first place. Both are knowable inside thirty days.
What to do now
| ▪ | Ask your administrator how many arbitration disputes your plan was party to in 2026 and what the average award was, with an answer due in 30 days. | | ▪ | Request in writing the method your administrator uses to set the qualifying payment amount, before your 2027 renewal signs. | | ▪ | Rank the top 10 facilities where your members receive out-of-network emergency or ancillary care, by spend. |
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| Source: Paragon Health Institute, analysis of CMS federal independent dispute resolution data |
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| 3 · MEDICAL INFLATION · September 11, 2026 |
| Consumer Medical Inflation Ran 1.6 Percent Over the Year While All Items Ran 3.4 Percent |
| The Bureau of Labor Statistics published the August 2026 Consumer Price Index on Friday, September 11, 2026, release USDL-26-1496. The all items index rose 3.4 percent for the twelve months ending August, and the release lists medical care among the notable increases over the last year at 1.6 percent. Month to month, the medical care index decreased 0.2 percent in August after rising 0.4 percent in July, seasonally adjusted. Also month to month, the hospital services index, physicians' services index and prescription drugs index were all unchanged in August, and the index for dental services fell 0.6 percent. On an unadjusted twelve-month basis, Table 1 puts medical care commodities at negative 2.7 percent and medical care services at 2.5 percent. The index measures what consumers pay out of pocket at retail, weighted to household spending, and the release says nothing about employer plans, employer premiums or self-funded plans. |
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MOC Perspective
Your CFO reads the consumer number, then reads a renewal quote near double digits, and wants to know which one is lying. Neither is. The index tracks retail prices paid by households, while your plan pays negotiated facility and professional rates the index never touches. Have that answer written down before the budget meeting, because the gap will come up, and the honest version of it makes a better case for reopening your contracts than any projection you can buy.
What to do now
| ▪ | Write a one-page note for your CFO separating the consumer figure from your own plan's trend, with both twelve-month figures on it, ready for your budget meeting. | | ▪ | Pull your 2026 claims trend split into unit price and utilization, and name which of the two drives more than half. | | ▪ | Ask your administrator in writing for your top five facility rate increases effective January 1. |
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| Source: U.S. Bureau of Labor Statistics, Consumer Price Index, August 2026, release USDL-26-1496 |
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| 4 · PREVENTIVE COVERAGE · September 17, 2026 |
| HHS Added Eight Members to the Task Force Whose Ratings Drive Your No-Cost Preventive Coverage |
| The Department of Health and Human Services announced on September 17, 2026 that Secretary Robert F. Kennedy, Jr., through the Agency for Healthcare Research and Quality, had added eight new members to the U.S. Preventive Services Task Force. Seth J. Corey is named Chair, alongside Patrick K. Hunter, Ronald P. Karlsberg, Venkatesh L. Murthy, Stephen T. Parente, Goldie Stands-Over-Bull, Louis J. Wilson and Dennis W. Wulfeck. The announcement says the new members "will join the eight members currently serving on the Task Force," which puts the panel at sixteen. HHS describes the Task Force as a volunteer panel making "evidence-based recommendations about clinical preventive services such as screenings, counseling, and preventive medications." It names no removals and no departures. It also says nothing about insurance, coverage or cost sharing, so the line from the Task Force's A and B recommendations to first-dollar preventive coverage in non-grandfathered plans comes from section 2713 of the Public Health Service Act and its implementing regulation at 45 CFR 147.130, not from this announcement. |
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MOC Perspective
Nothing about your covered preventive services changes today. What changed is the membership of the panel whose A and B recommendations your plan must cover with no cost sharing, and a new recommendation reaches you at the start of the first plan year beginning a full year after it issues. That interval is your planning window, so know what your preventive benefit costs now.
What to do now
| ▪ | List every preventive service your plan covers with no cost sharing and total the 2026 spend on the top five. | | ▪ | Ask your administrator how it tracks Task Force recommendation changes and how fast it loads them, and get the answer before January 1. | | ▪ | Set a calendar check on the Task Force recommendation list for January 1 and again for July 1. |
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| Source: U.S. Department of Health and Human Services |
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| 5 · DELAYS AND DENIALS · September 15, 2026 |
| Employer and Medicaid Members With Multiple Conditions Report Delays or Denials at the Same Rate |
| KFF published findings from its Survey of Health Access and Caregiving on September 15, 2026, in a report on adults living with multiple or complex health conditions. Respondents were asked whether their insurance company had denied coverage for or delayed their ability to get a service, treatment or medication their doctor prescribed in the past two years. Among adults aged 18 to 64 with multiple health conditions, 49 percent of those on an employer-sponsored plan reported a delay or denial, and 50 percent of those on Medicaid, and 54 percent of those with non-group coverage. KFF writes that for adults in that age range with conditions such as diabetes and cardiovascular disease there is "a similar pattern, with similar shares of adults reporting problems with their insurance company regardless of the source of their coverage." Nearly half of the group, 46 percent, is covered through an employer. The survey was conducted with the SSRS Opinion Panel from May 4 to May 26, 2026 among a nationally representative sample of 25,873 U.S. adults, with a margin of sampling error of plus or minus 1 percentage point for the full sample. KFF breaks out no employer-specific figure for medical bills, medical debt or skipped care, so this is the only employer cut in the report. |
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MOC Perspective
Employer coverage is the most expensive coverage in the country, and on this measure its members describe the same experience as Medicaid members. The finding is the sameness rather than a gap, and KFF says so plainly. This is self-reported member experience over two years, not a measured denial rate, which is exactly the reason to go and get your own measured rate. Your administrator already has it and most sponsors have never asked for it.
What to do now
| ▪ | Ask your administrator for your 2026 prior authorization denial rate and your appeal overturn rate, and put a 30 day deadline on the request. | | ▪ | Count how many appeals your plan received in 2026 and how many were decided in the member's favor. | | ▪ | Add one question on denials and delays to your open enrollment survey before enrollment opens. |
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| Source: KFF, Survey of Health Access and Caregiving |
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The Bottom Line
Four of these five stories are about something decided outside your plan and handed to you as a result: what an arbitrator awards a provider, what a price index reports, what a panel of experts recommends, what an insurer decides about a treatment a doctor prescribed. Connecticut is the exception, and it is the one worth copying, because a plan sponsor wrote the terms it wanted into what it buys rather than waiting for a law to arrive. Renewal season closes in roughly ten weeks. Every question above is one your administrator will answer if you ask now.
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Jude Odu
Founder and Principal, Model Optimal Care
Author of Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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