Payer Portrait

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.

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 the largest integrated delivery network in the U.S. The company operates 39 hospitals, employs more than 20,000 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 plus the District of Columbia. The seven combined entities form the largest provider-sponsored insurer in the U.S., enrolling 29.5% of all provider-sponsored lives.

MMIT Payer Portrait: Health Care Service Corp.

Health Care Service Corporation (HCSC) is the parent company of five large, member owned Blues insurers: Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas. The five subsidiaries enroll more than 16 million lives nationwide across the spectrum of health insurance products, though much of their membership is concentrated in Illinois and Texas. Originally founded in 1936 in Chicago as a prepaid insurance plan for hospital care, HCSC now enrolls more than half of all insured lives in Illinois.

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. It also participates on those states’ Affordable Care Act exchanges. Highmark’s offerings include commercial, Medicare Advantage and Medicaid products.

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 4.1 million lives. In addition to its public-sector products, Molina also offers Affordable Care Act exchange plans in 12 states. After receiving a contract extension in 2019, CVS Caremark will continue to serve as the insurer's pharmacy benefits manager through 2021, and no plans for a possible successor have been announced.

MMIT Payer Portrait: Humana Inc.

Humana Inc. is the sixth-largest health insurer in the U.S., serving more than 12.8 million lives across most sectors. Originally founded in the 1960s as a chain of nursing homes, the company has a long history in elder care, with nearly 40% of its members enrolled in Medicare Advantage (MA). Expounding on this legacy, Humana on April 27 revealed plans to acquire Kindred at Home, a large provider of home health and hospice services. Humana currently has a 40% stake in the company, and plans to leverage the acquisition to improve patient outcomes and satisfaction in in-home settings, according to a press release.

MMIT Payer Portrait: UnitedHealthcare

UnitedHealthcare (UHC), the health insurance unit of UnitedHealth Group, Inc., is the largest health insurer in the U.S., offering products across all sectors. Nationally, UHC is the top insurer in the group risk, administrative services only (ASO) and Medicare Advantage (MA) markets. As of March 2021, United controls a whopping 26.7% of the national MA market, and has expanded its presence significantly year over year since 2018.

MMIT Payer Portrait: Anthem, Inc.

Anthem, Inc. is the second-largest health insurer in the U.S., serving more than 33 million lives nationwide. It is also the largest Blue Cross and Blue Shield affiliate, acting as a Blues licensee in 14 states. Anthem's in-house PBM unit, IngenioRx, manages most of its pharmacy benefits, though CVS Specialty Pharmacy serves as its specialty PBM vendor. Anthem also operates Anthem Behavioral Health, and completed an acquisition of Beacon Health Options, one of the largest independent providers of behavioral health services in the U.S., in May 2020.

MMIT Payer Portrait: Cigna Corp.

Cigna Corp. is the fifth-largest health insurer in the U.S., serving more than 15 million lives nationwide. More than 80% of its members are enrolled in administrative services only (ASO) contracting arrangements. While Cigna largely covers employer groups, the insurer is working to expand its individual and Medicare Advantage (MA) business, bringing its Affordable Care Act exchange plans to 79 new counties in 2021 while also expanding its MA reach to 80 new counties for the 2021 plan year. The push to expand into these markets may be partially fueled by the nationwide job losses caused by the COVID-19 pandemic, as Cigna's overall membership is down 8.7% from 4Q19.