ACA, Medicare and Medicaid regulation
Regulatory Exposure
Significant federal/state regulation of licensing, premiums, provider contracting; ACA and Medicare/Medicaid funding, reimbursement, rate-setting and eligibility changes have adversely affected and could adversely affect results.
Relevance 95·Dependency 90·Confidence 95
Source evidence
“changes in government regulations, policies or funding that apply to government-sponsored programs such as Medicare and Medicaid including, among other things, reimbursement levels, quality-based bonus payment determinations, eligibility and redetermination requirements”
U.S. government agencies
Customer Exposure
Approximately 32% of 2025 consolidated revenues came from U.S. government agencies, mostly in the Health Benefits segment; changes to Medicare/Medicaid funding and rates directly affect results.
Relevance 95·Dependency 90·Confidence 98
Source evidence
“Through our participation in various federal government programs, we generated approximately 32%, 31% and 29% of our total consolidated revenues from agencies of the U.S. government for the years ended December 31, 2025, 2024 and 2023, respectively.”
Medical cost inflation
Cost Driver
Advances in medical technology, drug utilization, demographics and regulation contribute to rising healthcare costs; medical cost inflation among factors that may impair cost prediction and profitability.
Relevance 90·Dependency 85·Confidence 94
Source evidence
“medical cost inflation; increased labor costs; provider and member fraud; evolution of new technologies, drugs and treatments”
Blue Cross and Blue Shield Association license agreements
Regulatory Exposure
BCBSA licenses underpin brands and service areas; negative events or business combinations could risk license termination; BCBSA agreements add minimum capital and liquidity requirements.
Relevance 85·Dependency 85·Confidence 92
Source evidence
“We are also a party to license agreements with the BCBSA which contain additional minimum capital and liquidity requirements.”
CMS Star Ratings / Medicare Advantage quality bonus program
Demand Driver
CMS Star Ratings performance influences Medicare Advantage reimbursements and eligibility for quality-based bonus payments; maintaining/improving ratings is a disclosed risk and funding consideration.
Relevance 85·Dependency 80·Confidence 94
Source evidence
“our performance under the Centers for Medicare & Medicaid Services (“CMS”) Star Ratings program, which influences Medicare Advantage plan reimbursements as well as our eligibility to earn quality-based bonus payments for those plans”
CarelonRx pharmacy services
Revenue Exposure
CarelonRx is a reportable segment providing pharmacy services; pharmacy benefit costs are a significant component of healthcare costs and product revenue includes CarelonRx ingredient costs and service fees.
Relevance 85·Dependency 75·Confidence 93
Source evidence
“Product revenue represents services performed by CarelonRx for unaffiliated pharmacy customers and includes ingredient costs (net of any rebates or discounts), including co-payments made by or on behalf of the customer, and service fees.”
California, New York, Virginia, Indiana, Ohio, Georgia, Florida, Texas
Revenue Exposure
Largest revenue concentrations in eight states expose the company to state-specific or regional economic downturns and healthcare coverage changes.
Relevance 85·Dependency 75·Confidence 95
Source evidence
“The states in which we operate with the largest concentrations of revenues include California, New York, Virginia, Indiana, Ohio, Georgia, Florida and Texas.”
Health benefits industry competition
Competitive Exposure
Customers may renegotiate contracts or move to competitors for favorable premiums; Public Exchange plan selection is highly price sensitive.
Relevance 70·Dependency 55·Confidence 88
Source evidence
“Our customers may renegotiate their contracts to seek to contain their costs or may move to a competitor to obtain more favorable premiums. Public Exchange plan selection by our customers is also highly price sensitive.”
Enhanced PTC expiration / Public Exchange policy
Demand Driver
Public Exchange markets are volatile; potential changes relating to the expiration of enhanced premium tax credits at end of 2025 could affect results and enrollment assumptions.
Relevance 70·Dependency 55·Confidence 90
Source evidence
“including any potential changes relating to the expiration of enhanced PTCs at the end of 2025, could affect our results.”
Labor costs and workforce competition
Cost Driver
Increased labor costs are a healthcare cost factor; company faces intense competition to attract and retain associates which may increase salaries.
Relevance 65·Dependency 55·Confidence 90
Source evidence
“increased labor costs; provider and member fraud; evolution of new technologies, drugs and treatments”
Natural disasters, extreme weather and climate change
Geopolitical Exposure
Natural disasters and extreme weather have impacted customers, associates, facilities and vendors; climate change may increase disaster frequency/intensity with long-term impact on the health benefits and pharmacy services industries.
Relevance 65·Dependency 45·Confidence 90
Source evidence
“climate change could result in certain types of natural disasters occurring more frequently or with more intense effects, which could have a long-term impact on general economic conditions and the health benefits and pharmacy services industries in particular.”
Tariffs on pharmaceuticals
Cost Driver
Current and potential future tariffs are disclosed as a factor affecting pharmaceutical costs, a significant component of healthcare costs.
Relevance 60·Dependency 50·Confidence 88
Source evidence
“current and potential future tariffs and changes in discounts”
Artificial intelligence
Technology Dependency
AI failure to operate as intended and compliance with emerging AI laws/standards are disclosed risks; company also focuses on responsible AI adoption in talent development.
Relevance 60·Dependency 45·Confidence 90
Source evidence
“failure of our information systems or technology, including artificial intelligence, to operate as intended”