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Health Reform Coverage Expansions:Impact of Insurance Exchanges & Medicaid Expansion on Michigan Health Plans
July 2014avalere.com
Agenda
● Health Insurance Exchanges: National and Michigan Trends
o Enrollment
o Plan Participation & Premiums
o Benefit Design
o Looking Ahead to 2015
● Medicaid
o Expansion in Michigan
o Benefit Design
o Growing Role of Managed Care
● Opportunities and Challenges for the Future
2
Post-ACA Environment Yields New Payer and Provider Dynamics and Shift of Focus to Consumers
3
Evolving Insurance Landscape
Coverage of new lives; Evolution of employer-sponsored market1
2
Increased Consumer Engagement
Consumer choice in insurance coverage and treatment decisions3
Quality and Evidence
Value-based purchasing; Use of evidence in coverage decisions4
Role of Government as a Payer
Increase in government-sponsored/controlled lives post-20145
Transformation of Provider Business Models
Rise of integrated systems and consolidation; Providers taking on risk
Government Programs Will Play Larger Role for Managed Care Industry In the Short Term, Growing By More 84 Percent
4
14 15
33 46
25
144
147
16
10
314 325
2013 2017
ENROLLMENT BY PAYER TYPE (IN MILLIONS), 2013 & 2017
Uninsured
Medicaid Fee-For-Service
Medicare Fee-For-Service
Non Group
Employer
Exchanges
Medicaid Managed Care
Medicare Advantage
Source: Avalere Enrollment Model for All Payers, and Specialized Models for Medicare, and Medicaid, January 2013, Assumes 23 states opt out of the Medicaid expansion).
Significant Government
Role
Limited Government
Role
Other
Growing
Gov’t
Role
Enrollment in managed care programs with a significant government role is expected to grow from 23% in 2013 of total managed care business to 35% in 2107.
Health Insurance Exchanges in 2014
Michigan’s Exchange Is Operated by the Federal Government Through HealthCare.Gov
6
Source: Avalere State Reform Insights, June 13, 20141 ASPE Health Insurance Marketplace Summary Enrollment Report For The Initial Annual Open Enrollment Period; For the period: October 1, 2013 -March 31, 2014.
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCO
UT
TX
NM
SC
FL
GAAL
MS
LA
AR
MO
IA
VA
NCTN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
D.C.
2015 INSURANCE EXCHANGE OPERATIONAL MODEL
State-Run (12 + DC)
Federally-Facilitated Exchange (28)
Partnership (6)
Transitioning from state-based IT to HealthCare.gov platform (2)
State-Run, transitioning from HealthCare.gov platform to state-based IT (2)
Despite the tumultuous roll-out of
the HealthCare.gov website, a total of
273,000 Michiganders1
enrolled in an exchange plan
through the federal site mid-April 2014.
MI Exchange Enrollees Are Slightly Younger than the National Average
6% 6% 6%
26% 29%40%
39%38%
37%
30% 27%17%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total US Enrollment* MichiganEnrollment*
Potential USMarket** (2013)
55 and Over
35-54
18-34
Under 18
EXCHANGE ENROLLMENT BY AGE
7
*These numbers are based on the latest HHS Enrollment Report on enrollment through April 19. In general, enrollments reflects those choosing a plan. **”Distribution of Potential Individual Market Enrollees by Age” Kaiser Family Foundation analysis of the Survey of Income and Program Participation. December 13, 2013. http://kff.org/health-reform/perspective/the-numbers-behind-young-invincibles-and-the-affordable-care-act/Numbers may not equal 100% due to rounding within each age category.
The Vast Majority of Exchange Enrollees Receive Financial Assistance and Have Purchased Lower-Premium Plans
1% 2%
18% 13%
63% 75%
11%9%
6% 2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total MI
EXCHANGE ENROLLMENT BY METAL TIER*
Catastrophic Bronze Silver*
Gold Platinum
8
Updated: July 15, 2014, Avalere State Reform Insights
These numbers are based on the latest HHS Enrollment Report on enrollment through March 31, 2014. In general, enrollments reflects those choosing a plan. Numbers may not equal 100% due to rounding within each age category.FFE = Federally-Facilitated Exchange SBE = State-Based Exchange*Silver tier enrollment includes enrollees with cost-sharing reductions
With Financial
Assistance87%
Without Financial
Assistance13%
MICHIGAN EXCHANGE ENROLLMENT BY FINANCIAL
ASSISTANCE
Plans Strive to Keep Premiums Low, But Have Limited Flexibility on Benefit Design
Essential Health Benefits
Out of Pocket Limits
Guarantee Issue & Rating Rules
Actuarial Value
These parameters constrain plan flexibility…
9
…With Pressure to Keep Premiums Low, Plans Will Be Focused on Select Levers
• Network Design: Despite requirements that they must offer “adequate networks,” plans are designing high-value, narrow networks
• Formulary Design: Tier placement and utilization management will help plans manage drug use while still meeting EHB drug coverage requirements
• Cost-Sharing Requirements: Cost-sharing for specialty products in particular is expected to be high, and plans will structure cost sharing to encourage use of lower-cost products
EHB: Essential Health Benefits
BCBS of Michigan and Priority Health Have Major Footprints in Michigan’s 2014 Exchange Market
1010
AVERAGE PREMIUMS
BRONZE $357
SILVER $454
PLATINUM $495
GOLD $531
Source: Avalere analysis of information available on healthcare.gov at: https://data.healthcare.gov/dataset/QHP-Individual-Medical-Landscape/ba45-xusy, accessed October 3, 2013.1 ASPE Health Insurance Marketplace Summary Enrollment Report For The Initial Annual Open Enrollment Period; For the period: October 1, 2013 -March 31, 2014. *OPM plan offerings are included in the counts of the issuer offering the health plan.
Currently has over 10% market share in the individual market, in the state.
Exchange model: Federally-facilitated Actual 2014 enrollment:1
272,539Plans by Metal Tier:» Catastrophic: 10» Bronze: 14» Silver: 23» Gold: 21» Platinum: 4
Participating Plans*
Number of
Regions
Number of Plan Offerings
Ca
tas
t.
Bro
nze
Sil
ve
r
Go
ld
Pla
tin
.
To
tal
Blue Cross Blue Shield of Michigan
16 4 4 5 5 18
Consumer Mutual Insurance of Michigan
13 1 1 2 2 6
HAP 9 1 2 2 2 1 8
Humana 2 1 1 1 1 1 5
McLaren Health 11 1 2 2 2 7
Meridian 2 1 1 1 1 4
Molina 2 1 1 1 3
Priority Health 16 1 4 8 6 19
Total Health Care USA 3 1 1 2
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Washington
Vermont
Rhode Island
New York
Nevada
Minnesota
Massachusetts
Maryland
Kentucky
Connecticut
California Anthem Blue Shield of CAKaiser
PermanenteHealth Net Other
ConnectiCare Other
Neighborhood Health Plan Tufts
HealthNet
PreferredOne BCBS of MN
Health Plan of Nevada Anthem BCBS
Empire BCBSHealth Republic Fidelis Care EmblemMetroPlus Excellus Other
BCBS of RI Other
Premera Blue Cross Group Health LifeWiseCoordinated Care Other
BCBS of VT MVP
Other
Nevada Health CO-OP
Anthem
Kaiser
In Other States, Regional and Blue Plans Have Dominated Initial Enrollment, Though Premium Is the Key Driver
11Updated: July 2, 2014, Avalere State Reform Insights
ENROLLMENT BY ISSUER
Greatest Share of Enrollment
2nd Greatest Share of Enrollment
3rd Greatest Share of Enrollment
4th Greatest Share of Enrollment
5th Greatest Share of Enrollment
Other6th Greatest Share of Enrollment
Kentucky Health Cooperative Anthem Humana
BCBS of MA
Health Partners Other
St. Mary’s
CareFirst Blue Cross Blue Shield
Exchange Plan Deductibles Are Much Higher Than Those in Employer Plans, Especially in Bronze and Silver Plans
12
$4,959
$3,132
$1,713
$1,000
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Bronze Silver Gold Platinum
ME
DIC
AL D
ED
UC
TIB
LE
AVERAGE MEDICAL DEDUCTIBLES BY METAL LEVEL
*Average deductible for individual coverage;: Kaiser Family Foundation/ HRET 2013 Employer Health Benefits Survey. Source: Avalere PlanScape, Updated January 28, 2014. Avalere analysis HHS data file of all exchange plans in FFM states.
Employer: $1,135*
PCP Silver Plans Largely Offer Copays Between $21-40, and Most Gold Plans Use Copays under $40 for PCP Visits
13
16% 20%
44%
65%
8%
40%
38%
28%
14%
15%
3%
0%
22%
14%
13%4%
27%
10%2% 1%
14%2% 0% 1%
0%
50%
100%
Bronze Silver Gold Platinum
2014 AND 2015 PCP COST-SHARING BY METAL LEVEL
PE
RC
EN
T O
F P
LA
NS
$0 - $20
$21 - $40
$41 and over
USE OF COPAYS:
0- 20 %
41% or more
USE OF COINSURANCE:
21 - 40 %
Source: Avalere PlanScape, updated November, 2014. PCP: Primary Care Physician Note: When plans indicated “no charge” in the HHS Landscape file, Avalere assigned the plan to $0 copayment or 0% coinsurance depending on which cost sharing type was most prevalent for the specified benefit. For PCP visits, Avalere used $0 copayment.
Specialty Tiers Are Much More Common in Exchanges & Part D Compared to Employer Plans
14
3%19%
9%3%
59%91% 94%
23%
Exchange (2014) Medicare Part D (2014) Employer (2013)*
Two or Fewer Tiers Three Tiers Four or More Tiers
DISTRIBUTION OF FORMULARIES BY NUMBER OF TIERS,BY MARKET SEGMENT
PE
RC
EN
T O
F P
LA
NS
*Employer data represented distribution of covered workers whereas exchange and Part D data represent distribution of plans.
Source for Exchange Data: Avalere PlanScape, Updated November 2013. Avalere collected plan information from both federally-facilitated and state-based exchanges and captured a sample of over 600 plans for the analysis. Source for Employer Data: Kaiser Family Foundation and Health Research & Educational Trust, Employer Health Benefits 2013 Annual Survey. Source for Part D Data: Avalere Health analysis using DataFrame®, a proprietary database of Medicare Part D plan features, Updated October 2013.
Over 50% of Bronze and Silver Plans, Which Have the Highest Enrollment, Use Coinsurance on Their Specialty Tiers
15
16%
37%42%
73%
27%
6%
8%
18%25%
28%
17%
25%17%
16%
8%14% 15%6% 2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bronze Silver Gold Platinum
FR
EQ
UE
NC
Y O
F C
OS
T S
HA
RIN
G T
YP
E
Co-Payment No Charge After Deductible Coinsurance: 0%-29%
Coinsurance: 30%-49% Coinsurance: 50% and Higher
PLAN SPECIALTY TIER COST SHARING IN FFM STATES, BY METAL LEVEL
Source: Avalere PlanScape, Updated January 28, 2014. Avalere used a deduped version of the official HHS data file of all plans and benefit designs in FFM states to determine cost sharing.
Silver Plan Variations Are Most Likely to Reduce Deductibles, Least Likely to Reduce Formulary Tiers 3 & 4
16
PERCENT OF SILVER PLAN VARIATIONS THAT ALTER COST-SHARING STRUCTURE** FROM THE STANDARD SILVER PLAN*
74%
31%
25%22% 22%
13%
5%
96%
61%
52%57%
69%
58%
39%
96%
70%
64%68%
75%
63%
53%
MedicalDeductible
Primary CareCost Sharing
Specialist CostSharing
Formulary Tier1 Cost Sharing
Formulary Tier2 Cost Sharing
Formulary Tier3 Cost Sharing
Formulary Tier4 Cost Sharing
73% AV CSR Plan
87% AV CSR Plan
94% AV CSR Plan
*Data in the Landscape file is structured into four formulary tiers. For plans that have fewer or more than four formulary tiers, the data in this file may be inaccurate. ** For the purposes of this analysis, Avalere used the coinsurance and copayments amounts that applied after the deductible was met. Plans that noted that there was no charge, or no charge after the deductible was met were excluded. Amounts are rounded to the nearest dollar or percent.Source: Avalere PlanScape, updated March, 2014. Avalere collected plan information that was publically available in the 11th volume of the HHS Landscape File, accessed via: https://www.healthcare.gov/ . The file contained 5,800 silver plans spanning 34 FFM states. AV = Actuarial Value CSR = Cost Sharing Reduction
Looking Ahead to 2015
Oct 14-November 3: Certifications announced and agreements signed with HHS
As the 2015 Benefit Year Approaches, Carriers Must Meet Major Milestones in the QHP Application and Certification Process
Nov 15-Feb 15: 2015 Open enrollment
18
Initial FFM Review of
QHP Applications
FFM Reviews of Corrected
QHP Applications
2014 June July Aug Sept Oct Nov Dec 2015 Jan Feb
Jan. 1: FF-SHOP goes live
Aug. – Nov.: 2015 Rates Released
FFM = Federally Facilitated MarketplaceSHOP = Small Business Health Options ProgramQHP = Qualified Health PlanHHS = Department of Health and Human Services
New Carriers Will Enter Michigan’s Exchange in 2015 and Existing Carriers Will Expand Their Product Offerings
19Source: Avalere State Reform Insights, June 26, 2014Based on publically available proposed rate filings and press as of June 26, 2014.
UnitedHealthcareCommunity Plan,
Inc.
UnitedHealthcareCommunity Plan,
Inc.
Joining ~24 exchanges in 2015
Offering plan in 2 Regions
2 Bronze5 Silver2 Gold
1 Platinum
Physicians Health Plan
Physicians Health Plan
Offering plan in 5 Regions
1 Catastrophic3 Bronze3 Silver2 Gold
1 Platinum
Harbor Health Plan
Harbor Health Plan
Offering plans in 1 Region
1 Bronze1 Silver1 Gold
Total Number of Plans Offered in 2014: 60
Total Number of Plans Offered in 2015: 187
Average Premiums in Michigan Will Decrease and the Variation in Premiums Will Narrow Slightly in 2015
20
$190
$219
$328 $317
$484 $483
$-
$100
$200
$300
$400
$500
2014 2015
MO
NT
HLY
PR
EM
IUM
AVERAGE SILVER PLAN PREMIUMS FOR 40 YEAR OLD NONSMOKER
Lowest Premium Average Premium Highest Premium
Number of Carriers in 2014: 9Number of Carriers in 2015: 13Source: Proposed MI rate filings. http://www.michigan.gov/difs/0,5269,7-303-13047_34537-265512--,00.html
Some of the Low-Cost Carriers in 2014 Are Increasing Rates in 2015
21
AVERAGE SILVER PLAN PREMIUMS FOR A 40-YEAR-OLD NON-SMOKER IN MI
Source: Proposed MI rate filings. http://www.michigan.gov/difs/0,5269,7-303-13047_34537-265512--,00.html* Blue Cross BlueShield of MI includes Blue Care Network of Michigan products.** Both rates for 2014 and 2015 represent the average premium for all products offered by Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan.^ HAP include Alliance Health and Life Insurance Company products.*** Rates for 2015 represent the average premium for all products offered by HAP and Alliance Health and Life Insurance Company.
IssuerAverage 2014
RateAverage 2015
Rate% Change
Humana. $191 $231 +20.9%
Total Health Care. $224 $243 +8.5%
Meridian $263 $252 -4.2%
McLaren $275 $288 +4.7%
Blue Cross Blue Shield of Michigan* $287** $316** +10.1%
HAP^ $324 $302*** -6.8%
Molina $327 $334 +2.1%
Priority Health $340 $330 -2.9%
Consumers Mutual $414 $384 -7.2%
United Healthcare $245
Harbor Health Plan $302
Physician’s Health Plan $334
Michigan Average $328 $317 -3.4%
Automatic Renewals Allow Plans to Maintain Current Customers, but Some Enrollees Will Face Avoidable Premium Increases
22
$57 $72
$167 $171
$-
$50
$100
$150
$200
$250
$300
2014 2015
Monthly Premium and Subsidies for Sue, 2014-15
Premium Subsidy
Enrollee Premium
$224$243
Sue’s Story:• Earnings: $17,235/ year
(150% FPL)• Silver Plan Change:
2014 benchmark plan is 11th-lowest-cost silver plan in 2015
• If Sue keeps her plan in 2015, she will pay 26% more in premiums
The proposed renewal process gives plans broad flexibility to re-enroll individuals in their current plans – potentially leading to higher costs for enrollees.
Medicaid
Michigan Joins 27 Other States And DC in Expanding Medicaid Eligibility
24
Source: Avalere State Reform Insights, Updated June 23, 2014*Denotes states pursuing premium assistance models using exchange plans for part of their expansion populations: AR and IA have received waiver approval; PA submitted a waiver request for a plan using premium assistance that would take effect in 2015; NH will begin enrolling newly-eligible beneficiaries in MCOs in July 2014 with coverage effective August 15, and plans to move these beneficiaries into premium assistance in 2016, pending waiver submission and approval; if TN, VA, or UT expand, it is likely to be via premium assistance or another source of private coverage. **IN’s expansion received CMS approval of the Healthy Indiana Program 2.0 waiver and will likely take effect in 2015.
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KSCO
UT*
TX
NMSC
FL
GAALMS
LA
AR*
MO
IA*
VA
NCTN*
IN**
KY
IL
MI
WI
PA*
NY
WV
VT
ME
RICT
DE
MD
NJ
MANH*
WA
OH
DC
Will Expand (28 + DC)
Will Not Expand (19)
STATE COMMITMENT TO EXPAND MEDICAID ELIGIBILITY
States to Watch (3)
Michigan’s Expansion Plan Is Rooted in a Unique, Commercial-Style Approach
25
MICHIGAN’S PLAN CALLS FOR THE STATE TO USE TWO WAIVERS FOR COST-SHARING FLEXIBILITY
• Creates Health Savings Accounts for beneficiaries
• The plan includes cost-sharing requirements for all enrollees and premium contributions for those over 100% of the Federal Poverty Level (FPL)
• Some beneficiaries >100% FPL would pay cost sharing (up to 7% of income) or enter the exchange after 4 years
• Cost sharing reduced (to 2%) for “healthy behaviors”
• Trigger mechanism to rollback expansion if the second waiver not approved before 2016 OR if state savings are inadequate to offset costs when federal funding drops from 100%
Waiver 1 - ApprovedWaiver 2 – Proposed for
Approval in 2015
Healthy Michigan Offers Newly Eligible Beneficiaries A Benefits Package Similar to That Offered to Currently Eligible Beneficiaries
26
Annual Health Risk Assessment
• Physical activity
• Nutrition
• Alcohol, tobacco, and substance use
• Mental Health
• Flu Vaccination
Annual Health Risk Assessment
• Physical activity
• Nutrition
• Alcohol, tobacco, and substance use
• Mental Health
• Flu Vaccination
Covered Services
• 10 Essential Health Benefits
• Additional services include:
• Non-Emergency Medical Transportation
• Family Planning
• Vision Services
• Hearing Services
• Adult Dental Services
Covered Services
• 10 Essential Health Benefits
• Additional services include:
• Non-Emergency Medical Transportation
• Family Planning
• Vision Services
• Hearing Services
• Adult Dental Services
Groups and Services Exempt
from Cost Sharing
• Certain groups are exempt from co-pays (e.g., beneficiaries under 21, nursing home residents, etc.)
• Certain covered services do not have a co-pay requirement
• (e.g., Emergency Services, Family Planning Services, etc.)
Groups and Services Exempt
from Cost Sharing
• Certain groups are exempt from co-pays (e.g., beneficiaries under 21, nursing home residents, etc.)
• Certain covered services do not have a co-pay requirement
• (e.g., Emergency Services, Family Planning Services, etc.)
Cost Sharing
• Co-pays range from $1-$3 for all services except inpatient hospital stays ($50)
• Co-pays are applied to Emergency Room visits that are not true emergencies
Cost Sharing
• Co-pays range from $1-$3 for all services except inpatient hospital stays ($50)
• Co-pays are applied to Emergency Room visits that are not true emergencies
By selecting an alternative benefit package (ABP) that aligns with Michigan’s exchange benchmark plan, essential health benefits (EHB) will be consistent between the
exchange and Medicaid in the state.
Medicaid MCOs are Participating in Both the Healthy Michigan Expansion Plan and The Traditional MI Medicaid Program
27
13 Medicaid MCOs Participate in MI
Healthy Michigan Plan
Traditional MI Medicaid Program
The 8 MCOs offering both Medicaid health plans and QHPs in the exchange are well positioned to care for beneficiaries who may churn between Medicaid and the
exchange.
Medicaid MCO enrollment is projected to increase by
485,000 in MI from 2013 to 2016.1
"Source: Avalere Analysis using Avalere Medicaid Managed Care Enrollment Model, scenario 2, in which 23 states do not expand Medicaid; updated April 23, 2014."
Nationwide, 72% of Medicaid Beneficiaries Will Receive Medical Benefits Through Managed Care Plans by the End of 2014
30
32
4043
44
18 17
1514 13
0
10
20
30
40
50
60
70
2012 2013 2014 2015 2016
PROJECTED MEDICAID NON-DUAL, MEDICAL BENEFIT ENROLLMENT (IN MILLIONS), 2012-2016
FFS
MCO
75%
25%
77%
23%
Source: Avalere Analysis using Avalere Medicaid Managed Care Enrollment Model, scenario 2, in which 23 states do not expand Medicaid; updated April 23, 2014.FFS: Fee-for-serviceMCO: Managed Care Organization
72%
28%
35%
65%
37%
63%
28
29
Meanwhile, States Will See “Churn” Between Medicaid and Other Sources of Coverage
Medicaid Exchanges6.9M Churn
Annually
Disrupts continuity of care & medication
adherence
Creates possible gaps in coverage
Discourages insurer investment in longer-
term wellness
Increases administrative burden
to states
Problems Created by “Churn”
Source: Urban Institute analysis of 2001 and 2004 Survey of Income and Program Participation, “Churning Under the ACA and State Policy Options for Mitigation,” June 2012, Matthew Buttgens, Austin Nichols, and Stan Dorn.
Opportunities and Challenges for the Future
31
Exchange Benefit Design May Accelerate Shift to Narrower Commercial Coverage by Employers
EXCHANGE BENEFIT DESIGNS MAY HAVE SPILLOVER EFFECTS BY SETTING A NEWSTANDARD FOR COVERAGE GENEROSITY
Commercial
Exchange
L ives Served by Marke t Today
Ant i c ipa ted Fu tu re Marke t
Less Generous More Generous
Benefit Design Generosity
MedicaidCatastrophic
Continue to Offer
Coverage
Restructure Contributions
Offer Coverageto Limited
Group
Drop Coverage and Gross-up Wages
Drop Coverage with NoWage Gross-up
Continued Cost Growth and the ACA Are Leading Employers to Consider Alternatives To Current Benefit Structures
Based on “Performance in an Era of Uncertainty”, 17th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care , March 2012.
DEFINED CONTRIBUTION HEALTH BENEFIT STRATEGIES
32
Impact of Defined Contribution Benefit Strategies on…
Employers: Employees:
• Administrative simplification (fewer decisions on behalf of employee)
• More predictable financial exposure to health care costs
• Eventual decrease in financial burden
• Increased choice in insuranceoptions
• Increased variation in premiums and out-of-pocket costs between plans
• Eventual increase in financial burden
Hospital Mergers & Increasing Integration with Physicians Yields More Provider Consolidation in Many Markets
PERCENT OF PHYSICIANS INTERESTED IN PURSING INTEGRATION, 2010*
44
8 8 9
24
29
46
38
34
21
51
0
% Currently in this Model % Intend to Pursue within 2 Years
Employment Joint Venture
Co-MgmtCompany
Leasing Directorships, Stipends &
Management Contracts
No Integration
Recent Acquisitions Position Commercial Health Plans to Grow Government Segments & Serve Integrated Providers
34
United Healthcare
XLHealth
AIM Healthcare
Axolotl
Picis
Monarch Healthcare
Aetna
Coventry
Active Health
Medicity
WellPoint
Amerigroup
CareMore
Resolution Health
Humana
Metropolitan Health
Networks
American Eldercare
Cigna
HealthSpring
Universal American
Collaborative Health
Systems
APS Healthcare
