MMIT Payer Portrait: Aetna

CVS Health Corp.’s Aetna is the third-largest health insurer in the U.S., serving more than 22 million lives across all market sectors. Nationally, Aetna ranks No. 3 in administrative services only (ASO) non-risk contracting, No. 4 in the group risk commercial market and No. 3 in Medicare Advantage (MA), an area of significant investment for the insurer in recent years. For the 2023 plan year, Aetna will expand its MA offerings to 141 new counties across its 46-state market, compared to 83 counties in 2022. And as the COVID-19 pandemic rattled the employer group markets, Aetna in 2022 returned to the Affordable Care Act (ACA) exchanges after pulling out in 2018. While it enrolls just under 60,000 exchange lives as of October 2022, its footprint will expand to four additional states in 2023.

As a unit of CVS Health, Aetna manages its own pharmacy benefits through Aetna Pharmacy Management, though some lines of business are managed by Caremark. CVS Specialty handles much of the insurer’s specialty contracting, though like other insurers, Aetna contracts with many PBMs for specialty drug management.

Since its 2018 acquisition of Aetna, CVS has leveraged its newfound status as one of the largest payers in the U.S. to home in on primary care and hybridized insurance products. Aetna is a key component in CVS’s effort to reformat its drugstores into HealthHUBs, which feature expanded clinic services, primary care visits, blood testing and health screening labs, plus areas devoted to wellness. From 2020 to 2022, CVS launched several versions of its Aetna Connected plans in key metro areas, which offer employer groups $0 copay appointments at HealthHUB stores and MinuteClinics, free prescription delivery and in-store discounts, among other benefits. Aetna has also bolstered the company’s financial performance, fueling its standout first-quarter and strong second-quarter in 2022.

Furthering its primary care strategy, the company in December 2021 said it expects to spend up to $25 billion on provider M&A through 2023. Yet its first major target since that announcement was home health company Signify Health, following a bidding war that shot up to $8 billion. “[Home health] is a really important part of that continuum of care,” Ashraf Shehata, national sector lead for health care and life sciences at KMPG, told AIS’s Health Plan Weekly in August 2022, when the deal was still a rumor. “The belief is that, as inpatient bed days get a little bit more constrained, patients need to be able to get discharged to the home with some level of high-degree services. And those services are now reimbursable….If you’re an insurer, if you have a retail environment, if you have a PBM, it’s a natural part of that continuity of care.” The deal is expected to close in the first half of 2023.

CVS has also hedged its bets on virtual care in the wake of the COVID-19 pandemic. In January 2023, the company is launching a virtual primary care platform for select Aetna and Caremark members. The platform will offer both telehealth and the option to schedule in-person clinician visits at CVS locations, in addition to medication management and mental health services.

SOURCE: AIS’s Directory of Health Plans as of October 2022; MMIT Analytics as of 4Q 2022.

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