Opus Health Plan — YTD Through February 2026 Analysis
Through February 2026, Opus still looks favorable overall, but January was unusually helped by timing items, and February is the better read on underlying spend. Even February is still immature because a large portion of current costs has not fully developed yet.
Key Findings: YTD Through February 2026
YTD through Feb 2026 is running better than prior year despite slightly higher enrollment. Average employees are up to 1,020.5 from 995.5 and average members are up to 1,521.5 from 1,478.5. Even so, the results are strongly favorable versus Jan–Feb 2025.
-6.7%
Medical Down
Year-over-year reduction in medical costs
-14.9%
Rx Down
Year-over-year reduction in Rx costs
-21.3%
Gross Plan Cost Down
Year-over-year reduction in gross plan cost
-30.0%
Net Employer Cost Down
Year-over-year reduction in net employer cost
January Was Abnormally Favorable
January was abnormally favorable. January gross plan cost was only $509,370, and net employer cost was $236,273. January should not be treated as a normal baseline month.
$187,939 Rx Rebate
A significant Rx rebate materially reduced January net cost and is not expected to recur at the same level every month.
$91,553 Stop-Loss Reimbursement
Stop-loss reimbursement provided an additional one-time benefit to January's favorable result.
Essentially No Personify Runout ($206)
Personify runout was virtually zero in January, which further suppressed costs in an atypical way.
January should not be treated as a normal baseline month. All three of these items are timing-driven and do not reflect the underlying run rate of the plan.
February Rose Sharply — But Mostly for Explainable Timing Reasons
February gross plan cost increased to $901,528 and net employer cost to $718,873. The increase was driven by identifiable timing and runoff factors — the February increase is not just "utilization getting worse." A large part of it is timing and runoff.
1
Loss of Rx Rebate
+$187,939 cost swing from loss of the January Rx rebate benefit
2
Loss of Stop-Loss Reimbursement
+$91,327 cost swing from loss of the January stop-loss reimbursement benefit
3
Personify Runout
Personify runout jumped to $84,924 in February versus essentially zero in January
4
Higher Medical Spend
Higher current medical spend at Leading Edge of +$28,367 month over month
Both January and February Are Still Favorable to Budget
Both January and February are still favorable to budget. Compared with the monthly budget in the file, the plan is tracking well ahead of expectations on a YTD basis.
$618,535
January Favorable Variance
January was favorable versus monthly budget by approximately this amount
$131,758
February Favorable Variance
February was favorable versus monthly budget by approximately this amount
$750,293
YTD Favorable Variance
Combined YTD favorable variance through February 2026
The Biggest Actuarial Caution: Reserve Development
IBNR Reserve Estimate
The medical IBNR report shows a 12/12 rectangle estimate of $1,093,617, and about 57% of that reserve is tied to Jan–Feb 2026 incurred months. Said differently, the first two months of 2026 are still very immature, so current paid claims almost certainly understate ultimate cost.
Claim Lag Supports That Reserve Concern
In the medical lag schedule, only about 23% of January medical paid was for January 2026 service dates, and only about 20% of February medical paid was for February 2026 service dates. A very large share of each month is still prior-month runoff, especially December 2025 and January 2026 services. That means February is not fully accounted for.
The first two months of 2026 are still very immature — current paid claims almost certainly understate ultimate cost. February is not fully accounted for.
Stop-Loss Is Not Yet the Story for 2026 Claims Emergence
Stop-loss is not yet the story for 2026 claims emergence. Current stop-loss reports still show no claimant above 50% of the $250,000 specific deductible and zero specific stop-loss claims through February.
Aggregate Attachment Through February
Approximately $2.50 million — the threshold that must be reached before aggregate stop-loss applies
Current LEA Medical + Rx Claims
Approximately $1.25 million — current incurred claims through February 2026
Block as % of Aggregate Attachment
The block is only around 50% of aggregate attachment at this point — stop-loss is not yet triggered
Utilization Reports: Meaningful Severity in the Population
The utilization reports still show meaningful severity in the population. For the Mar 2025–Feb 2026 period, Opus had 53 inpatient admissions, 317 inpatient days, and 46 members admitted.
Avoidable ER visits also increased materially to 29 from 4 in the comparison period.
ER Performance vs. Benchmark
175 ER visits per 1,000 versus a 205 benchmark — still better than benchmark on a broad basis.
$2,286 allowed per visit versus a $2,856 benchmark — cost per visit also favorable.
Enrollment Trend
Membership in the utilization report rose from 1,489 to 1,520, which is directionally consistent with the monthly totals showing a modest enrollment increase.
That said, ER performance is still better than benchmark on a broad basis despite the increase in avoidable ER visits.
Savings Opportunities and Pended Claims
The Savings-Opportunity Model Is Meaningful, But It Is Still a Model
The annual projection shows about $787,269 of new savings opportunities from stop-loss premium savings, Good Samaritan-type intervention, Payer Matrix assumptions, and UBF fee reduction. On that modeled basis, January net employer cost would fall to about $181,299 and February to about $639,390. These should be presented as modeled opportunity, not realized savings.
Pended Claims Should Be Discussed Carefully
Pended claims include about $1.756 million of allowed amounts, but roughly 88% of that sits in administrative categories like precertification not obtained and other insurance information required. That makes it a monitoring item, not a clean "this will all hit next month" liability.
Total modeled savings opportunity: $787,269 annually. These are modeled projections and should not be treated as realized savings.
Bottom-Line Summary
YTD through February is still favorable versus both prior year and budget, but January was artificially light because of rebates/reimbursements and almost no runoff. February is the more realistic month, and even that is understated because reserves remain heavy and claim development is immature. The core ongoing risks are inpatient severity, developing medical runout, and utilization pressure, not an immediate specific stop-loss issue.
YTD Position
Still favorable versus both prior year and budget through February 2026
January Caveat
Artificially light due to rebates, reimbursements, and almost no runoff — not a true baseline
February Reality
More realistic month, but still understated because reserves remain heavy and claim development is immature
Core Ongoing Risks
Inpatient severity, developing medical runout, and utilization pressure — not an immediate specific stop-loss issue
Notation
Due to monthly reconciliation by LEA, there will be changes in various areas of reporting. The monthly reports are updated for prior months to reflect the most accurate information and will thus result in some differences from month to month.