Blue Cross Blue Shield plans faced widespread financial pressure in 2025, with several major insurers posting operating losses as medical and pharmacy costs continue to climb. The struggles played out across several leadership moves, an evolving reimbursement policy landscape and notable state and federal legislative battles.
Seven key BCBS updates in 2026:
1. Financial
- Combined profit margins across BCBS plans sank to 1.4% as of third-quarter 2025. As of Sept. 30, BCBS plans account for 37.2% of national health insurance enrollment, or 119 million members.
- BCBS Minnesota posted a $353 million operating loss and a net income of $83 million in 2025
- BCBS Rhode Island posted a $10 million operating loss and $150 million in net income in 2025.
- BCBS Vermont posted a $53 million operating gain and net income of $63.3 million in 2025.
- BCBS Michigan posted an underwriting loss of $975.5 million and net loss of $246 million in 2025.
- BCBS Massachusetts posted an operating loss of $380.5 million and a net loss of $222.8 million in 2025.
- In 2025, Regence BlueShield in Washington state reported an operating loss of nearly 8% on total revenue of $2.38 billion and a net loss of 3.1% in 2025. Regence BCBS in Oregon posted a 1.3% operating loss on revenue of $3.18 billion and 1.5% net income. Regence BlueShield of Idaho reported an operating loss of 0.5% on revenue of $752 million and net income of 2.5%. Regence BCBS of Utah reported net income of 3.5% on total revenue of $1.45 billion
- Highmark Health Plans reported a $609 million operating loss in 2025.
- Elevance Health reported operating revenue of $197.6 billion and nearly $5.7 billion in profits in 2025.
2. Leadership moves
- CareFirst BCBS named Kurt Small as its next president and CEO, effective May 4.
- BCBS Wyoming President and CEO Diane Gore will retire after 40 years with the organization and Kris Urbanek, currently executive vice president, will take her place, effective May 1.
- Louisiana Blue President and CEO Bryan Camerlinck is set to retire at the end of 2026.
- BCBS Vermont President and CEO Beth-Ann Roberts started in her role in January.
- BCBS North Dakota market president Lacey Bergh started in her role in February.
- Anthem BCBS Georgia named Amanda Free as president and Jessica Lopez-Liggett was named commercial state plan president of Anthem BCBS Indiana in February.
- BCBS Kansas City President and CEO Erin Stucky will retire by the end of 2026 and Jenny Housley has been named her successor.
- Highmark BCBS West Virginia President Jay Sheehy started in his role in 2026.
3. M&A
- BCBS Kansas City and Highmark earned regulatory approval from Missouri officials in March to close their affiliation deal.
- Hawaii Medical Service Association and Honolulu-based Hawaii Pacific Health said in January they plan to come together under a new organization called One Health Hawaii.
- BCBS North Dakota and Cambia Health Solutions earned regulatory approval from North Dakota officials on their affiliation deal in January.
- BCBS Michigan is selling its AF Group subsidiary to Enstar Group, a global insurance and reinsurance group, by the end of 2026.
4. Medicare Advantage
- Elevance Health is facing a possible enrollment suspension with some of its MA plans over what CMS has characterized as “substantial and persistent noncompliance” with risk adjustment data submission requirements.
- CareFirst BCBS sued CMS in January over its 2026 MA star ratings, alleging improper calculations cost the insurer an estimated $32 million in quality bonus payments.
- The BCBS Association is asking CMS to close certain MA fraud gaps and regulate AI coding tools used in risk adjustment audits.
5. No Surprises Act
- Elevance Health has been rolling out a new policy across 13 states throughout this year, where in-network facilities that use out-of-network providers to treat Anthem commercial members in inpatient or outpatient settings may face an administrative penalty equal to 10% (7.5% in New York) of the allowed amount of claims involving those providers. Continued use of out-of-network providers could result in termination from Anthem’s network entirely. Elevance has defended the policy as a response to what it characterizes as widespread misuse of the IDR process.
- The BCBS Association told CMS the independent dispute resolution process is broken and needs structural fixes. The organization recommended that the agency launch the IDR Gateway as soon as possible, implement baseline eligibility screening before payment or review, establish an upfront eligibility fee to deter bad-faith submissions, and create performance metrics.
- Premera Blue Cross sued a weight loss clinic, its physician-owner and its RCM firm in April, alleging repeated abuse of the IDR process.
- BCBS Texas sued medical billing company Zotec Partners in December, alleging abuse of the IDR process.
- Blue Cross of Idaho requested a state investigation into Nutex Health’s IDR billing practices in November, then brought its case before the state legislature in early 2026. A bill backed by the insurer that would have capped reimbursements for out-of-network freestanding ERs passed the Idaho Senate but failed to advance in the House before lawmakers adjourned in April.
6. Reimbursement policy updates
- Anthem Blue Cross of California paused its upcoming evaluation and management claim downcoding policy until at least May 1.
- BCBS Michigan will cut reimbursement by 50% for nonpreventive evaluation and management services billed with modifier 25 on the same day as procedure codes with global periods of zero or 10 days, effective May 1.
- Independence Blue Cross enacted a severity-based payment approach for emergency inpatient admissions under Medicare Advantage in March.
- BCBS Illinois will begin downcoding office, inpatient, and outpatient evaluation and management services that do not align with the level billed, effective July 1.
7. Pharmacy
- Florida Blue launched two specialty pharmacy programs in 2026 aimed at reducing drug costs for members on high-priced therapies. One program, which routes specialty prescriptions through a bidding process among participating pharmacies, is already generating $4 million to $5 million in monthly savings.
- BCBS Michigan saved $67 million and $80 million in 2024 and 2025, respectively, through biosimilar use, the insurer said in February.
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