Payer Portrait

MMIT Payer Portrait: Blue Shield of California

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.

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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. 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.

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MMIT Payer Portrait: Alignment Healthcare

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.

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MMIT Payer Portrait: Oscar Health, Inc.

Founded in 2012, Oscar Health Inc. bids itself as “the first health insurance company built around a full stack technology platform.” Since its founding, Oscar has grown to serve more than 900,000 members in 19 states (though it will exit California for the 2024 plan year), largely via the Affordable Care Act (ACA) exchanges and off-exchange individual and family plans. The startup also offers Medicare Advantage plans in Florida and partners with Cigna Healthcare on co-branded small group products. For the 2024 plan year, Oscar will expand to 512 counties in its existing state markets, focusing on underserved and rural areas. The insurer is also expanding the availability of its diabetes-focused plan and will launch a new product called Breathe Easy, which offers enhanced services to members with chronic obstructive pulmonary disease (COPD) and asthma.

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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 one of the largest integrated delivery networks in the U.S. The company operates 39 hospitals, employs more than 23,000 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 and Washington, D.C. The company will expand to Pennsylvania with its planned acquisition of Geisinger Health, a health system that operates the fourth-largest public-sector health insurer in the state. The deal also marks the advent of Kaiser's Risant Health, a new nonprofit subsidiary that aims to expand the adoption of value-based care nationwide.

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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 million lives. In addition to its Medicaid products, Molina also offers Affordable Care Act exchange plans in 16 states and is growing its Medicare Advantage (MA) business. The insurer in June unveiled a $600 million deal to acquire struggling insurtech Bright Health's California MA assets, which is expected to close in the first quarter of 2024. Molina has been on an acquisition spree of smaller, public sector-focused insurers in recent years. Other deals include its purchases of YourCare Health Plan, Affinity Health Plan, Magellan Complete Care, Senior Whole Health, Passport Health Plan and My Choice Wisconsin.

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MMIT Payer Portrait: Humana Inc.

Humana Inc. is the sixth-largest health insurer in the U.S., serving more than 13 million lives nationwide. The insurer ranks No. 2 in Medicare Advantage (MA), behind UnitedHealthcare. Originally founded in the 1960s as a chain of nursing homes, the company has a long history in elder care, with more than 40% of its members enrolled in MA. Humana in 2021 unveiled a new direction for the company, introducing its payer-agnostic health care services division CenterWell. CenterWell's scope includes senior-focused primary care, home health and pharmacy benefits management. Humana in February 2023 said it will exit its commercial insurance markets and focus entirely on the public sector (Medicare, Medicaid and TRICARE), winding down its fully insured, self-funded and Federal Employee Health Benefit plans over the next 18 to 24 months.

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MMIT Payer Portrait: Centene Corp.

Centene Corp. is the fourth-largest health insurer in the U.S., serving more than 21 million lives nationwide. The insurer ranks No. 1 in national managed Medicaid enrollment, holding contracts with 28 states. The insurer also dominates the Affordable Care Act (ACA) exchanges, leading the market with more than 3 million members in 27 states. The company is undergoing a multiyear value-creation program designed to control future administrative costs and focus on its core business — health insurance. In 2022, Centene sold two of its pharmacy businesses, Magellan Rx and PANTHERx Rare, in deals totaling $2.8 billion. The company in June 2023 divested Apixio, its artificial intelligence value-based care platform, to New Mountain Capital.

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MMIT Payer Portrait: Blue Cross Blue Shield of Michigan

Founded in 1939 as a wave of prepaid insurance groups that later became Blue Cross and Blue Shield plans spread across the country, Blue Cross Blue Shield of Michigan (BCBSM) is now the largest insurer in the state of Michigan and the fifth-largest Blues affiliate in the U.S. Though its main focus is employer-sponsored commercial insurance products in its home state, BCBSM also offers Medicare Advantage (MA) plans nationwide. It consistently ranks among the top 10 national MA payers, making it unique among regionally focused Blues plans. Aside from Michigan, its largest MA markets are in Florida, Indiana and Vermont. BCBSM made waves in May 2023 when it struck a cashless "affiliation deal" with Blue Cross and Blue Shield of Vermont, which will place the Vermont Blues insurer under the BCBSM umbrella if approved by state regulators.

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MMIT Payer Portrait: UnitedHealthcare

UnitedHealth Group's UnitedHealthcare is the largest insurer in the U.S., with membership approaching 50 million lives. In addition to health insurance, United's stalwart health services unit, Optum, powers pharmacy benefits management, specialty drug management, care delivery, population health services and data and analytics. United and Optum arguably set the trend toward increased payer integration, fueling a wave of consolidation that sparked CVS Health's purchase of Aetna, Cigna Corp.'s acquisition of Express Scripts and Elevance Health's launch of Carelon (then Anthem and IngenioRx). Optum in October 2022 completed its acquisition of Change Healthcare, giving the company unprecedented insight into patient, claims and outside payer data.

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