In an unpublished memorandum decision, the Ninth Circuit in R.R. v. California Physicians’ Service d/b/a Blue Shield of California, affirmed the insurer and administrator’s denial of benefits for a dependent’s residential mental health treatment under an ERISA‑governed plan. The court applied abuse‑of‑discretion review and concluded that the denial was supported by the plan’s medical‑necessity criteria and the administrative record. The dissent, however, argued that the majority failed to meaningfully account for a structural conflict of interest and for the administrator’s handling of treating‑provider evidence and prior failed lower levels of care.

On January 26, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2027 Advance Notice of Methodological Changes for Medicare Advantage (MA) capitation rates and Medicare Part D payment policies. CMS projects a net average year‑over‑year MA payment change of just 0.09% — roughly a flat environment once medical trend, utilization, and other pressures are considered. CMS frames the proposal as improving “payment accuracy and sustainability,” with a focus on aligning payments more closely with actual beneficiary risk and care rather than documentation intensity.