Monthly Claims Report
January 2026
Opus — January 2026 Monthly Claims & Cost Summary
Paid Month: 1/1/2026 – 1/31/2026 | Reporting Snapshot
This paid-month summary captures all claims paid during January 2026. The reporting population includes 1,018 employees (subscribers) and 1,541 total members. January incorporates a small amount of Personify runout, with the remainder of claims processed and paid through Leading Edge (LEA).
Section 1
Claims Paid in January — Medical + Rx
Total claims paid during January 2026 came in at $619,123, translating to a per-employee-per-month (PEPM) cost of $608.18. This represents a significant year-over-year decline from January 2025, driven by favorable experience across both medical and pharmacy channels.
Total Claims Paid
$619,123
$608.18 PEPM
Medical Paid
$426,882
$419.33 PEPM
Rx Paid
$192,241
$188.84 PEPM
Rx rebates recorded in January 2026: $0. Rebate timing should be monitored as future postings will reduce net Rx costs in subsequent months.
Year-Over-Year Trend
January Paid Claims — Three-Year Comparison
January 2026 claims declined sharply compared to the prior year, falling 28.5% from $865,884 in January 2025 to $619,123. Medical claims dropped 29.1% and pharmacy claims declined 27.2%. However, when compared to January 2024, total claims are up 34.7%, reflecting the natural growth in plan enrollment and utilization trends over a two-year horizon.
-28.5%
YoY Change
2026 vs. 2025 total claims
+34.7%
2-Year Change
2026 vs. 2024 total claims
1,018
Employees
Current subscriber count
Section 2
Total Plan Costs — Claims + Fixed, Net of Stop-Loss
This section aligns with the plan experience accounting framework, combining paid claims with fixed costs and netting any stop-loss reimbursements recorded during the month. The total January 2026 net plan cost after stop-loss came in at $676,697, which includes $676,491 from Leading Edge operations and approximately $206 from Personify runout.
Fixed costs — comprising stop-loss premium and administrative fees — totaled $149,127 for the month. The plan benefited from $91,553 in stop-loss reimbursements, which offset a portion of the high claims expense and brought the net cost down meaningfully relative to gross paid amounts.
January 2026 Cost Bridge
Cost Bridge Detail — Personify vs. Leading Edge
The following breakdown illustrates how January 2026 plan costs flow from paid claims through fixed costs and stop-loss offsets to arrive at the net plan cost. Personify runout activity was minimal, representing only $206 in residual medical payments, with no pharmacy, rebate, or stop-loss activity.
Personify Runout
Medical Payment: $206
Rx Payment: $0
Rx Rebates: $0
Stop-Loss: $0
Personify Total: $206
Leading Edge (LEA)
Total 2026 Plan Costs (Personify + LEA): $676,697 | $664.53 PEPM (LEA)
Section 3
Employer Net Cost & Budget Comparison
After deducting employee contributions of $273,097 ($268.27 PEPM), the net employer cost for January 2026 settles at $403,600, or $396.46 PEPM. This result is substantially below the projected budget, generating a favorable surplus that reflects both lower-than-expected utilization and effective cost management.
1
Projected Costs
$850,631
$835.59 PEPM budgeted
2
Actual Plan Costs
$676,697
$664.53 PEPM net of stop-loss
3
Favorable Surplus
$447,031
$439.13 PEPM under budget
Net Employer Cost PEPM — Three-Year Trend
January 2026 employer PEPM cost is 48.2% lower than January 2025 and 11.7% lower than January 2024 — a strong indication that the plan is performing well within budget parameters entering the new plan year.
Section 4
Watch List
High-Cost / Shock Claim Note
The Leading Edge shock claims listing through January 31, 2026 identifies one notable claimant that warrants ongoing monitoring. High-cost claimants can create significant paid-month volatility, and early identification enables proactive care management intervention and accurate forecasting of future liabilities.
OPS1 — Multiple Sclerosis
Total Cost: $41,921.20
- Medical component: $40,933.41
- Rx component: $987.79
This claimant should remain on the active watch list for ongoing high-cost monitoring. Multiple sclerosis therapies — particularly specialty biologics and disease-modifying agents — can drive sustained high-cost claims in subsequent months. Coordination with the stop-loss carrier is recommended to ensure timely reimbursement should this claimant breach the specific deductible threshold.
Section 5
Forward-Looking
Emerging Items — Impact on Future Paid Months
Several items are not fully reflected in January paid-month totals and could materially increase future paid months as they are resolved or released for payment. Stakeholders should account for these when interpreting trend and forecasting upcoming cost run rates.
Personify Runout — Unpaid Balance Bills
Approximately ~$100,000 in balance bills remain outstanding through the Personify platform and have not yet been paid. When these amounts are released and processed, they will increase future paid-month costs. These should be tracked as runout liability rather than attributed to January utilization, ensuring accurate trend interpretation.
Pending Claims Inventory (LEA)
Approximately ~$150,699 of allowed pending claims remain in process within the Leading Edge system. As these pended items resolve and pay, they could add meaningfully to next month's paid claims and total plan cost. This creates paid-month volatility that is operational and timing-driven (pend resolution) rather than a true increase in incurred utilization trend.
Combined exposure: The Personify balance bills (~$100K) and LEA pending inventory (~$150.7K) represent approximately $250,700 in potential future paid-month additions. Monitor these closely in February and March reporting.
Reference
Standard Definitions for Monthly Reporting
To ensure consistency in interpretation across all monthly reporting periods, the following standard definitions apply to key metrics referenced throughout this summary. These definitions form the basis of the paid-month accounting framework used for Opus plan experience tracking.
Claims Paid (Med + Rx)
Paid claims activity during the month, reported on a cash / paid-month basis. This captures all medical and pharmacy claims that were adjudicated and released for payment within the reporting period, regardless of the date of service.
Net Plan Cost After Stop-Loss
Total paid claims plus fixed costs (stop-loss premium and administrative fees) minus stop-loss reimbursements recorded in the month. This metric reflects the plan's true economic cost after accounting for risk transfer mechanisms.
Net Employer Cost
Net plan cost minus employee contributions. This represents the employer's residual financial obligation after member cost-sharing and is the primary metric for budget variance analysis and funding adequacy assessment.
Summary
Key Takeaways — January 2026
January 2026 delivered a strong start to the plan year, with favorable claims experience across both medical and pharmacy lines. The plan is tracking significantly under budget, though several forward-looking items require continued monitoring.
Claims Down 28.5%
Year-over-year paid claims declined sharply from January 2025
$447K Under Budget
Favorable surplus driven by lower utilization and effective cost management
~$250K Pending
Balance bills and pended claims may increase future paid months
1 Shock Claimant
MS diagnosis at $41.9K — on active watch list for continued monitoring
Recommended Actions: Continue monitoring the OPS1 shock claimant, track Personify runout liability resolution, and review LEA pending inventory clearance in February reporting to assess true incurred trend.