Payer Portrait

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.

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.

As the largest health insurance companies become increasingly diversified, Anthem, Inc., the second-largest insurer in the U.S., rebranded as Elevance Health in June 2022. In addition to its legacy insurance business, Elevance offers technology-enabled health care solutions, pharmacy benefits management, data analytics, behavioral health and population health management via Carelon, its health care services unit. Its various payer subsidiaries include Anthem Blue Cross Blue Shield, Amerigroup, WellPoint, Empire Blue Cross Blue Shield and MMM Healthcare. Elevance was founded in Indiana in 1946 as a mutual insurance company, eventually growing to become the largest Blue Cross and Blue Shield affiliate in the U.S. Gail Boudreaux has served as Elevance's CEO since 2017.

Independence Health Group is the parent company of Independence Blue Cross, the second-largest Blues insurer in Pennsylvania (behind Highmark Health), and AmeriHealth Caritas, a managed Medicaid payer serving more than 2.3 million beneficiaries in seven states and the District of Columbia. It also operates the AmeriHealth Insurance Company of New Jersey, a commercial payer serving about 209,000 members. Founded in 1938 as the Associated Hospital Service of Philadelphia, Independence now counts more than 4.5 million members across the spectrum of health insurance products. Still based in Philadelphia, it leads its home state’s individual, self-funded (administrative services only, or ASO) and managed Medicaid insurance markets. Optum’s FutureScripts serves as the primary pharmacy benefits manager for Independence Blue Cross. AmeriHealth Caritas, meanwhile, operates its own in-house PBM, PerformRx.

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.

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.

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.

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.

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.

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.