Payer Portrait

MMIT Payer Portrait: The Lifetime Healthcare Cos.

The Lifetime Healthcare Companies are the parent organization of New York-based Blues insurer Excellus Blue Cross Blue Shield and Univera Healthcare. Combined, the companies are the sixth-largest insurer in New York, largely focusing on the Western and upstate New York markets. Lifetime on May 22 unveiled plans to acquire Capital District Physicians' Health Plan, Inc. — better known as CDPHP — a physician-founded nonprofit payer based in Albany, N.Y., that serves about 375,000 members. It offers employer group products and Medicare Advantage plans, and holds a New York Medicaid contract. CDPHP also operates ConnectRx, a community-based full-service pharmacy.

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MMIT Payer Portrait: Clover Health

Founded in 2014, Clover Health is a Medicare Advantage-focused startup insurer that has grown to serve nearly 80,000 members across five states. The insurtech focuses on "physician enablement," empowered through its software platform, Clover Assist. Clover Assist aggregates patient data to support provider decision-making and identify early areas of intervention in patients with chronic diseases. Like its fellow insurtechs, Clover has struggled financially since becoming a publicly traded company, though it shows signs of achieving profitability as early as year-end 2024.

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MMIT Payer Portrait: CareSource

Founded in Dayton, Ohio, in 1989, CareSource is a not-for-profit health insurer that serves Medicaid, Medicare-Medicaid dual eligibles and Affordable Care Act (ACA) exchange members in six states, though Ohio remains its largest market. The insurer in recent years has faced a rocky road growing its Medicaid presence — it lost out on an Iowa contract, and its successful bid in Mississippi is held up by a legal standoff. CareSource has a pending Medicaid bid in Kansas but may be looking to the exchanges for faster expansion. The insurer in February struck an affiliation deal with Brookfield, Wis.-based Common Ground Healthcare Cooperative, one of the few remaining ACA CO-OP plans, which are governed by their members. Common Ground currently serves about 60,000 members.

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MMIT Payer Portrait: Point32Health

Canton, Mass.-based Point32Health was established Jan. 1, 2021, following the successful merger of Harvard Pilgrim Health Care and Tufts Health Plan, two major players in the New England health insurance markets. With more than 1.5 million members, Point32Health is one of the largest insurers in New England, serving members across the spectrum of insurance products. The org’s top state market is Massachusetts, where it is the second-largest insurer overall, behind UnitedHealthcare. The insurer in February 2024 unveiled plans to acquire Baystate Health's insurance subsidiary, Health New England. The deal would grow Point32Health’s membership by 11%, to more than 1.7 million lives, according to AIS's Directory of Health Plans.

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MMIT Payer Portrait: Blue Shield of California

Founded in 1938 as the California Physicians' Service, Blue Shield of California is now the fifth-largest insurer in its home state. While nearly 70% of its members are enrolled in employer-based insurance products, Blue Shield of California also offers Medicare Advantage and Affordable Care Act exchange plans. It acquired the Medicaid insurer Care1st Health Plan in 2015, which now operates as Blue Shield of California Promise Health Plan. In August 2023, the insurer made headlines for breaking with its longtime pharmacy benefits manager CVS Caremark in favor of a transparency-focused model in partnership with Amazon Pharmacy and Mark Cuban Cost Plus Drug Company, among others.

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MMIT Payer Portrait: Highmark Health

Highmark Health is a privately owned not-for-profit subsidiary of Highmark, Inc. and a Blue Cross and Blue Shield licensee for its insurance offerings in Delaware, Pennsylvania, New York and West Virginia. With its history as a hospital system dating back to the 1840s, Highmark is now the largest insurer in Delaware and Pennsylvania. The company also operates Allegheny Health Network, a Western Pennsylvania-based health system of 14 hospitals and more than 300 sites of care. This makes Highmark one of the largest integrated delivery networks in the U.S. Highmark expanded to New York with its 2021 acquisition of the payer HealthNow New York Inc. and its two regional Blues brands.

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MMIT Payer Portrait: Alignment Healthcare

Founded in 2013, Alignment Healthcare, Inc. is one of several tech-enabled startup insurance companies, also known as "insurtechs," that have gone public in recent years. Alignment brings a highly personalized, concierge approach to Medicare Advantage (MA) and also serves Medicare-Medicaid dual eligibles. The company has offered co-branded plans with Rite Aid since 2021 and for 2024 will partner with Walgreens and Instacart on new product offerings. Alignment's traditional and co-branded offerings are enhanced by supplemental benefits such as pre-loaded debit cards, flex allowances for dental, vision and hearing, as well as access to nontraditional medicine such as acupuncture and chiropractic care. While all of the public insurtechs have struggled to become profitable, Alignment's CEO John Kao projects the company will break even in 2024 and start turning a profit in 2025.

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MMIT Payer Portrait: Oscar Health, Inc.

Founded in 2012, Oscar Health Inc. bids itself as “the first health insurance company built around a full stack technology platform.” Since its founding, Oscar has grown to serve more than 900,000 members in 19 states (though it will exit California for the 2024 plan year), largely via the Affordable Care Act (ACA) exchanges and off-exchange individual and family plans. The startup also offers Medicare Advantage plans in Florida and partners with Cigna Healthcare on co-branded small group products. For the 2024 plan year, Oscar will expand to 512 counties in its existing state markets, focusing on underserved and rural areas. The insurer is also expanding the availability of its diabetes-focused plan and will launch a new product called Breathe Easy, which offers enhanced services to members with chronic obstructive pulmonary disease (COPD) and asthma.

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MMIT Payer Portrait: Kaiser Permanente

Kaiser Permanente, founded in 1945 as a consolidation effort between local hospitals in California and an insurance group for construction employees, has since become one of the largest integrated delivery networks in the U.S. The company operates 39 hospitals, employs more than 23,000 physicians in its medical groups and offers health insurance products in both the private and public sector markets. Kaiser’s seven regional managed care plans enroll more than 11 million lives in eight states and Washington, D.C. The company will expand to Pennsylvania with its planned acquisition of Geisinger Health, a health system that operates the fourth-largest public-sector health insurer in the state. The deal also marks the advent of Kaiser's Risant Health, a new nonprofit subsidiary that aims to expand the adoption of value-based care nationwide.

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MMIT Payer Portrait: Molina Healthcare

Founded by a physician in 1980 as a primary care clinic for low-income Californians, Molina Healthcare is now the fourth-largest Medicaid insurer in the U.S., serving more than 4 million lives. In addition to its Medicaid products, Molina also offers Affordable Care Act exchange plans in 16 states and is growing its Medicare Advantage (MA) business. The insurer in June unveiled a $600 million deal to acquire struggling insurtech Bright Health's California MA assets, which is expected to close in the first quarter of 2024. Molina has been on an acquisition spree of smaller, public sector-focused insurers in recent years. Other deals include its purchases of YourCare Health Plan, Affinity Health Plan, Magellan Complete Care, Senior Whole Health, Passport Health Plan and My Choice Wisconsin.

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