Payer Portrait

MMIT Payer Portrait: Blue Cross and Blue Shield of Louisiana

With more than 1 million members, Blue Cross and Blue Shield of Louisiana is the largest Blues affiliate in its home state and the second-largest insurer overall, behind UnitedHealthcare. Founded in 1934 as the Hospital Service Association of New Orleans, BCBSLA is now the 19th largest Blues insurer in the U.S. While the majority of its customers are employer groups, the insurer also offers coverage on the Affordable Care Act exchanges in Louisiana, as well as Medicare Advantage (MA) plans. It dominates Louisiana’s individual and group risk-based commercial markets, holding 88.5% and 74.5% of overall market share, respectively. Cigna Corp.’s Express Scripts currently serves as BCBSLA’s pharmacy benefits manager.

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MMIT Payer Portrait: Cigna Corp.

Cigna Corp. is the fifth-largest health insurer in the U.S., serving more than 15 million lives nationwide. Roughly 80% of its members are enrolled in administrative services only (ASO) contracting arrangements. While Cigna largely covers employer groups, the insurer is working to build its individual and Medicare Advantage (MA) businesses. The insurer will expand its Affordable Care Act exchange offerings to 50 new counties in Georgia, Mississippi and North Carolina in 2023 and add three new states — Indiana, South Carolina and Texas — to its market. Cigna currently ranks 12th in national exchange enrollment, with 307,500 members. In the MA arena, Cigna ranks 8th nationally. For the 2023 plan year, the company is expanding its MA plans to 106 new counties and two new states — Kentucky and New York.

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MMIT Payer Portrait: Sanford Health Group

Sanford Health Group is the health insurance unit of Sanford Health, a large, integrated nonprofit health system of 47 hospitals based in Sioux Falls, South Dakota. It is the second-largest insurer in both its home state and neighboring North Dakota and also has a presence in Iowa, Minnesota and Nebraska. Sanford largely serves the commercial health insurance markets, having a strong presence in both the North and South Dakota exchange markets. The majority of its members are enrolled in risk-based commercial insurance products. UnitedHealth Group’s OptumRx serves as Sanford’s pharmacy benefits manager and also facilitates most of its specialty pharmacy benefits.

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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.

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MMIT Payer Portrait: SelectHealth

SelectHealth is the wholly owned health insurance unit of Intermountain Healthcare, a Salt Lake City-based health system of 33 hospitals and more than 3,800 physicians. SelectHealth is the largest insurer in Utah and also has a presence in Idaho and Nevada. The majority of SelectHealth’s members are enrolled in commercial risk-based products, with the insurer holding a robust Affordable Care Act exchange presence in Utah, where it dominates the individual market. SelectHealth also holds a Medicaid contract in Utah and has expanded its Medicare Advantage presence in recent years.

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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.

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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. 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.

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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.

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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.

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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.

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