The Affordable Care Act (ACA) and Medicare Advantage (MA) plans continue to drive enrollment for major health insurance companies in the U.S., with ACA marketplace enrollment jumping 21% in 2022 and breaking records in 2023. Medicare Advantage plans are also on a steady climb, accounting for more than half of the eligible Medicare population in2023.
While scores of companies sell health insurance coverage in the U.S., a handful dominate the market. Here are the top five largest health insurance payors, based on total direct premiums earned in2021.
What is ahealthcare payor?
A healthcare payor (also called healthcare payer) is an organization that pays for the cost of healthcare services administered by a healthcare provider. Payors can be either government or private entities. Examples include commercial insurers and government programs like Medicare and Medicaid. The primary difference between a health plan and a payor is that a health plan pays the cost of medical care, and a payor is an entity responsible for processing patient eligibility, services, claims, enrollment,or payment.
Top 5 healthcare payors by total direct premiumearned
| Rank | Payor | Premium earned | Covered lives |
| 1 | Kaiser Permanente Health Plans | $56,425,475,223 | 9,245,150 |
| 2 | Elevance Health | $40,825,223,071 | 6,401,147 |
| 3 | UnitedHealthcare | $39,506,571,575 | 7,177,594 |
| 4 | Health Care Service Corporation Group | $33,910,149,836 | 5,180,391 |
| 5 | Florida Blue | $18,701,458,090 | 2,489,533 |
Fig. 1 – Data is from the Definitive Healthcare ConnectedCareView product, according to the most recent 12-month interval tracked in our database. Accessed September2023.
What was the top payor by premiums earned andcovered lives?
Many companies sell health insurance in the U.S., but a few large companies control a significant share of the market. Here’s a rundown of the top five largest health insurance payors in the U.S., based on total direct premiums earned in the most recent 12-month interval tracked in ourdatabase.
1. Kaiser Permanente HealthPlan
Kaiser Permanente Health Plans was the top payor by premiums earned ($56.4 billion) and covered lives (9.2 million) in 2021. Most of its covered lives (7.1 million) are in the large group segment. Kaiser has 1.1 million and 1.0 million covered lives in the individual and small group segments,respectively.
Kaiser Permanente’s membership primarily draws from the states where it operates: California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington, and Washington, D.C. Californians make up most of its membership. This is likely due to Kaiser’s long history in thestate.
Kaiser Permanente is a closed-network provider, which means that members must generally see Kaiser Permanente physicians and use Kaiser Permanente facilities to receive coveredcare.
2. Elevance Health (formerlyAnthem)
Anthem changed its name to Elevance Health in 2022. The company offers commercial, Medicare, and Medicaid plans through its affiliates, including Anthem Blue Cross and Blue Shield, Wellpoint, Carelon, andothers.
The payor saw $40.8 billion in total direct premiums earned and had 6.4 million covered lives in 2021. Plans operate in 14 states: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, andWisconsin.
3.UnitedHealthcare
UnitedHealth Group has two subsidiaries: Optum and UnitedHealthcare. It offers insurance under UnitedHealthcare and healthcare products under Optum. In 2021, UnitedHealthcare had $39.5 million in total premiums earned and 7.2 million coveredlives.
UnitedHealth Group health plans are available in all 50 states and the District of Columbia. The company offers employer, individual and family, Medicare, and Medicaid health insuranceplans.
4. Health Care Service Corporation(HCSC)
Health Care Service Corporation is an independent licensee of the Blue Cross and Blue Shield Association. In 2021, the payor saw $33.9 billion in total direct premiums earned and had 5.2 million covered lives. The company sells commercial, Medicare, and Medicaid plans in five states: Illinois, Montana, New Mexico, Oklahoma, andTexas.
5. FloridaBlue
Florida Blue (also known as Blue Cross Blue Shield of Florida) is a member of the Blue Cross Blue Shield Association, which is a network of independent Blue Cross Blue Shield health insurance companies. In 2021, the payor saw $18.7 billion in total direct premiums earned and had 2.5 million covered lives in 2021. All the company’s covered lives are inFlorida.
Payor vspayer
There is some conflict regarding the use of “payer” versus “payor.” Though people often use both spellings interchangeably, “payor” is preferred by the American Medical Association (AMA). Still, the term “payer” is also widely used in the healthcareindustry.
How can healthcare payors cutoverspending?
All-payor claimsdatabases
All-Payor Claims Databases (APCDs) are electronic systems that collect healthcare claims data from payors. As of 2020, 21 states had an APCD, and 11 states were interested in implementing one. To develop an APCD system, state governments must assess the local healthcare market. This includes evaluating the health insurance market and public payors, developing data submission guidelines and managing patient healthdata.
Though it seems like an immense amount of work and can be costly to maintain, the payoff is significant in population health monitoring and healthcare spending reduction. Because APCDs are statewide systems, they simplify data sharing between payors, providers and regulators. This allows for easy analysis of medical claims and identification of areas to prevent financialwaste.
Wasteful spending costs employers up to $2 billion per year or about one-fifth of the total spend, according to a 2017 report from the American Health Policy Institute (AHPI).
APCDs can also educate payors and other stakeholders on areas overutilizing healthcare services or where preventive care could have positively impacted overall spending. Once payors have this data, they can work with providers to deliver more comprehensive care, thus improving care outcomes and reducing costs. For example, an NIH study reviewing APCD data in Virginia found that unnecessary low-cost healthcare services, like lab tests and EKGs, cost more than $586 millionannually.
Blockchain
A 2020 CMS report shows out-of-pocket spending accounted for 9% of total national health expenditure. This means patients will have higher expectations for care outcomes, provider communication and data security. Like current EHR systems, blockchain eases communication between providers and payors, making data easily accessible to those who have permission to viewit.
Blockchain is an expandable list of electronic records that are connected and secured using encrypting technology. The adoption of blockchain in healthcare has been slow to start but has vast potential as electronic health records (EHR) and electronic medical records (EMR) become virtuallyomnipresent.
Since EHR systems and healthcare facilities can be vulnerable to cybersecurity breaches, implementing blockchain could save the healthcare industry as much as $100 billion per year by eliminatingfraud.
Like APCDs, blockchain compiles massive amounts of patient data, allowing easier analysis. This could allow employers who offer health plans to see the categories of care costing the most money and implement wellness initiatives to combat them. Blockchain could offer a window into why patients seek care, whether smoking cessation, weight loss or otherareas.
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