Payer Portrait

MMIT Payer Portrait: UPMC

UPMC Health Plan is the health insurance unit wholly owned by the University of Pittsburgh Medical Center (UPMC). UPMC operates a health system of 40 hospitals throughout Pennsylvania and Appalachian regions of New York and Maryland, as well as several international locations. Its health plans serve members across the spectrum of insurance products, including Pennsylvania’s managed Medicaid program and the Affordable Care Act exchanges. It is currently the third-largest insurer in the state. Cigna Corp.’s Express Scripts serves as UPMC’s primary pharmacy benefits manager, while Accredo Health Group, Inc. (a unit of Express Scripts) manages specialty pharmacy. UPMC manages its own behavioral health benefits.

MMIT Payer Portrait: Blue Cross and Blue Shield of North Carolina

Founded in 1933 as Durham, North Carolina’s Hospital Care Association, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is now the largest insurer in the state, serving nearly 3 million lives. It offers commercial health products, including plans sold on the Affordable Care Act exchanges in North Carolina, as well as Medicare Advantage (MA) and Medicaid plans. Blue Cross NC is the ninth-largest Blues affiliate in the U.S.

MMIT Payer Portrait: CareFirst BlueCross BlueShield

Founded in the 1930s by a Washington, D.C.-based hospital association, CareFirst BlueCross BlueShield is now one of the largest insurers in the Washington metropolitan area, leading the Maryland market and snagging the No. 2 spot in the District itself. It offers commercial health products, including plans sold on the Affordable Care Act exchanges in D.C., Maryland and Virginia, as well as Medicare Advantage (MA) and Medicaid plans. CareFirst is also the second-largest participant in the Federal Employee Health Benefits Program, behind Anthem, Inc., with about 627,000 members.

MMIT Payer Portrait: GuideWell Mutual Holding Corp.

Founded in 1944 as the Florida Hospital Service Corp., GuideWell Mutual Holding Corp. is one of the largest Blue Cross and Blue Shield affiliates in the U.S. GuideWell is the parent company of Florida Blue, Capital Health Plan, Inc., Florida Health Care Plan, Inc. and, as of Feb. 1, Triple-S Management Corp. With more than 3.7 million members enrolled its in commercial and Medicare Advantage products, Florida Blue is the largest insurer in Florida.

MMIT Payer Portrait: CareSource

Founded in Dayton, Ohio, in 1989, CareSource is a not-for-profit health insurer that serves Medicare, Medicaid and Affordable Care Act exchange members in five states, though Ohio remains its largest market. Following its founding mission of expanding health care access to needy populations, in 2015 the insurer branched out to seniors, launching its first Medicare Advantage (MA) plans in Ohio. CareSource also serves Ohio’s Medicare-Medicaid dual eligible population through the state’s CMS-backed duals demonstration program.

MMIT Payer Portrait: Bright Health

Founded as a consumer-oriented, technology-focused startup in 2015, Bright Health has quickly made its presence known in the health care industry, despite its newcomer status. The company launched its first product offerings in Colorado's individual market in 2016 and has since expanded to offering individual, Medicare Advantage (MA) and small group plans in 17 states. Bright Health's value-based care model revolves around partnerships with select health and hospital networks, including Tenet Health, Novant Health and HCA Healthcare, emphasizing the importance of the patient-provider relationship. CVS Caremark serves as Bright Health's pharmacy benefits manager.

Provider Lawsuit Could Tie Up Surprise Billing Regulations

The U.S.’s two largest health care provider groups, the American Medical Association (AMA) and the American Hospital Association (AHA), sued the Biden administration on Dec. 9, asking a federal court to block regulations officials developed to implement the No Surprises Act, parts of which will come into effect on Jan. 1. Health care attorneys tell AIS Health that the suit may hinge on the providers’ allegation that federal officials stretched their legal authority too far beyond the Act’s original intent — and that the providers might win.


MMIT Payer Portrait: Cambia Health Solutions

With its roots in the health insurance industry stemming back to 1917, Cambia Health Solutions is a nonprofit health insurance company and member of the Blue Cross Blue Shield Association, offering Blues products in Idaho, Oregon, Utah and Washington. Known as The Regence Group until 2013, Cambia operates four regional managed care organizations under its Regence BlueCross BlueShield branding. Outside of its Blues brands, Cambia also operates BridgeSpan Health Company, which focuses on Affordable Care Act exchange products, and Asuris Northwest Health, a community-based insurer offering commercial and Medicare Advantage plans in Washington state.

MMIT Payer Portrait: Oscar Health

Founded in 2012, Oscar Health Inc. calls itself “the first health insurance company built around a full stack technology platform.” Since its founding, Oscar has grown to serve more than 500,000 members in 18 states, largely via the Affordable Care Act (ACA) exchanges and off-exchange individual and family plans. Oscar also offers Medicare Advantage (MA) plans in three states and in 2020 partnered with Cigna Corp. to offer co-branded small group commercial products in California, Connecticut, Georgia, Missouri and Tennessee. CVS Caremark serves as Oscar’s pharmacy benefits manager.

MMIT Payer Portrait: Triple-S Management Corp.

Founded by a group of providers in 1959, Triple-S Management Corp. is now a publicly traded company and the largest insurer in Puerto Rico, serving 35% of the U.S. territory’s insured population. It is also the primary Blue Cross and Blue Shield affiliate for the island. Miami-based Abarca Health serves as Triple-S’s pharmacy benefits manager for commercial and Medicare products, while ProCare Rx subsidiary MC-Rx serves the Medicaid population.