Payer Portrait

MMIT Payer Portrait: Sentara Healthcare

Sentara Healthcare is a Norfolk, Virginia-based nonprofit health system of 12 hospitals and more than 300 other sites of care. Its health insurance unit, Sentara Health Plans, Inc., is the third-largest insurer in Virginia, though it also serves employer groups in Ohio and North Carolina on a smaller scale. Many of Sentara’s products are offered under its Optima Health branding. UnitedHealth Group’s OptumRx and Optum Specialty Pharmacy manage Sentara’s pharmacy benefits.

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. Its name, unveiled in June 2021, alludes to the 32 points on a compass and represents a shift toward person-centered, technology-focused care delivery, according to an article in the Boston Globe. With more than 1.7 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, serving the state’s managed Medicaid program and offering products through its Affordable Care Act exchanges. Notably, Point32Health is the largest Medicare Advantage insurer in Massachusetts, beating out UnitedHealthcare and Blue Cross Blue Shield of Massachusetts.

MMIT Payer Portrait: Priority Health

Priority Health is the insurance unit of BHSH Health, a health system of 22 hospitals based in Grand Rapids, Michigan. BHSH Health is the temporary name for the combined entity formed by the merger of Spectrum Health (the original owner of Priority Health) and Beaumont Health, which was finalized in February 2022. It is the second-largest health insurer in Michigan, serving members across the spectrum of insurance products, including Michigan’s managed Medicaid program and the Affordable Care Act exchanges. Cigna Corp.’s Express Scripts serves as Priority Health’s primary pharmacy benefits manager, while Accredo Health Group, Inc. (a unit of Express Scripts) manages specialty pharmacy.

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.

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.