Payer Portrait

L.A. Care Health Plan is the largest publicly operated health plan in the United States, serving more than 2.5 million members in Los Angeles County. It largely serves Medi-Cal, the state's managed Medicaid program, but also offers products on California's state-based health insurance exchange, Covered California. In 2022, the insurer launched a Dual Eligible Special Needs Plan (D-SNP) that coordinates both Medicare and Medi-Cal benefits. Additionally, its PASC-SEIU Homecare Workers Health Care Plan is specifically designed for Los Angeles residents working as in-home caregivers. Most recently, L.A. Care in August 2024 cut 24% of its prior authorization codes to help avoid delays in member care and speed up inpatient discharge requests.

UPMC Health Plan is the health insurance unit wholly owned by the University of Pittsburgh Medical Center. UPMC operates a large 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 its home state and the fourth-largest integrated insurer in the U.S. UPMC also operates a Program of All-Inclusive Care for the Elderly, Community LIFE, and is a joint owner of Maryland Physicians Care, a provider-sponsored managed Medicaid plan.

Priority Health is the health insurance arm of Corewell Health, the Grand Rapids, Mich.-based nonprofit health system of 22 hospitals formed by the merger of Spectrum Health and Beaumont Health. It is the second-largest health insurer in Michigan, behind Blue Cross Blue Shield of Michigan, serving members across the spectrum of insurance products, including Michigan’s managed Medicaid program and the Affordable Care Act exchanges. Priority Health will expand its reach to Indiana and Ohio with its planned acquisition of Physicians Health Plan of Northern Indiana, a small nonprofit insurer serving the employer group markets.

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.

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.

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.

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.

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.

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.

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.