UnitedHealth Group Incorporated operates as a diversified health care company.
The company’s two complementary businesses — Optum and UnitedHealthcare — are driven by the focus to improve health care access, affordability, experiences and outcomes for the individuals and organizations it serves.
The company has four segments across its two business platforms, Optum and UnitedHealthcare: OptumHealth; OptumInsight; OptumRx; and UnitedHealthcare, which includes UnitedHealthcare Employer & Individual, UnitedHealthcare Medicare & Retirement, UnitedHealthcare Community & State and UnitedHealthcare Global
Optum is a technology-enabled health services business that serves the health care marketplace, including those who need care: the consumers who need the right support, information, resources and products to achieve their health goals; those who provide care: pharmacies, hospitals, physicians, practices and other health care facilities seeking to modernize the health system and support the possible patient care and experiences; those who pay for care: employers; health plans; and state, federal and municipal agencies devoted to ensuring the populations they sponsor receive care; and those who innovate for care: global life sciences organizations dedicated to developing approaches to care, enabling technologies and medicines to improve care delivery and health outcomes.
Optum operates three business segments utilizing capabilities in health care delivery, population health, health care operations, data and analytics and pharmacy care services: OptumHealth focuses on care delivery, care management, wellness and consumer engagement, and health financial services; OptumInsight offers data, analytics, research, consulting, technology and managed services solutions; and OptumRx provides an array of pharmacy care services.
OptumHealth provides health and wellness care, addressing the physical, emotional and health-related financial needs of 98 million consumers, through a national health care delivery platform, which engages people in the appropriate care settings, including their homes. OptumHealth helps patients and providers navigate and address chronic and behavioral health needs; delivers local primary, specialty, surgical and urgent care; offers post-acute care planning services; and serves consumers and care providers through advanced, on-demand digital health technologies, such as telehealth and remote patient monitoring, and innovative health care financial services. OptumHealth works directly with consumers, care delivery systems, employers, payers, and government entities to improve quality, patient and provider satisfaction.
OptumHealth enables care providers’ transition from traditional fee-for-service payment models to performance-based delivery and payment models to improve patient health and outcomes. Through strategic partnerships, alliances and ownership arrangements, OptumHealth helps care providers adopt new approaches and technologies, improving the coordination of care across providers to serve patients.
Optum Financial, including Optum Bank, served consumers through 7.6 million health savings and other accounts and had various assets under management as of December 31, 2020. During 2020, Optum Financial processed various digital medical payments to physicians and other health care providers. Organizations across the health system rely on Optum to manage and improve payment flows through its automated, scalable, digital payment systems.
OptumHealth offers its products on a risk basis, assuming responsibility for health care costs in exchange for a monthly premium, on an administrative fee basis, managing or administering products and services in exchange for a monthly fee, or on a fee-for-service basis, delivering medical services to patients in exchange for a contracted fee. For financial services offerings, OptumHealth charges fees and earns investment income on managed funds.
OptumHealth sells its products primarily through its direct sales force, strategic collaborations and external producers in three key areas: employers, including large, mid-sized and small employers; payers, including health plans, third-party administrators (TPAs), underwriter/stop-loss carriers and individual product intermediaries; and government entities including the U.S. Departments of Health and Human Services, Veterans Affairs, Defense, and other federal, state and local health care agencies.
OptumInsight brings together advanced analytics, technology and health care expertise to deliver integrated services and solutions. Hospital systems, physicians, health plans, state governments, life sciences companies and other organizations, including the health care industry depend on OptumInsight to help them improve performance, meet compliance mandates and modernize their core operating systems to meet the needs of the health system. OptumInsight serves the needs of health systems (e.g., physicians and hospital systems), health plans, state governments and life sciences companies.
Health Systems: Serves hospitals, physicians and other care providers to improve revenue, coordinate care and reduce administrative costs through technology and services to improve population health management, patient engagement, revenue cycle management and strategic growth plans.
Health Plans: Serves health plans by improving financial performance and improving outcomes through analytics, a comprehensive payment integrity portfolio and staff-supported risk and quality services. OptumInsight helps health plans navigate environment defined by shifts in employer vs. government-sponsored coverage, the demand for affordable benefit plans and the need to leverage new technology to reduce complexity.
State Governments: Provides advanced technology and analytics services to modernize the administration of safety net programs, such as Medicaid.
Life Sciences Companies: Combines data and analytics expertise with comprehensive technologies and health care knowledge to help life sciences companies adopt a comprehensive approach to advancing therapeutic discoveries and improving clinical outcomes.
Majority of OptumInsight’s software and information products and professional services are delivered over extended periods. OptumInsight maintains an order backlog to track unearned revenues under these long-term arrangements.
OptumInsight’s products and services are sold primarily through a direct sales force. OptumInsight’s products are also supported and distributed through an array of alliances and business partnerships with other technology vendors, who integrate and interface OptumInsight’s products with their applications.
OptumRx provides a spectrum of pharmacy care services through its network of approximately 67,000 retail pharmacies, multiple home delivery, specialty and community health pharmacies and through the provision of in-home and pharmacy infusion services. OptumRx manages limited and ultra-limited distribution drugs in oncology, HIV, pain management and ophthalmology and serves the pharmacy needs of people with behavioral health and substance use disorders, particularly Medicare and Medicaid beneficiaries.
OptumRx’s comprehensive whole-person approach to pharmacy care services integrates demographic, medical, laboratory, pharmaceutical and other clinical data and applies analytics to drive clinical care insight to support care treatments and compliance, benefiting clients and individual consumers through enhanced services, elevated clinical quality and cost trend management.
OptumRx serves health benefits providers, large national employer plans, unions and trusts, purchasing coalitions and government entities. OptumRx’s distribution system consists primarily of health insurance brokers and other health care consultants and direct sales.
OptumRx offers multiple clinical programs, digital tools and services to help clients manage overall pharmacy and health care costs in a clinically appropriate manner, which are designed to promote health outcomes, and to help target inappropriate utilization and non-adherence to medication, each of which might result in adverse medical events affecting member health and client pharmacy and medical spend. OptumRx provides various utilization management, medication management, quality assurance, adherence and counseling programs to complement each client’s plan design and clinical strategies. OptumRx offers an approach to integrating the management of medical and pharmaceutical care by using data and advanced analytics to help improve comprehensive decision-making, elevate quality, close gaps in care and reduce costs for customers and people served.
Through its health benefits offerings, UnitedHealthcare is enabling health, creating a health care experience for its customers and helping to control rising health care costs.
UnitedHealthcare utilizes Optum’s capabilities to help coordinate and provide patient care, improve affordability of medical care, analyze cost trends, manage pharmacy care services, work with care providers and create a consumer and physician experience.
In the United States, UnitedHealthcare arranges for discounted access to care through networks which, as of December 31, 2020, included 1.4 million physicians and other health care professionals and approximately 6,500 hospitals and other facilities.
UnitedHealthcare Employer & Individual
UnitedHealthcare Employer & Individual offers an array of consumer-oriented health benefit plans and services nationwide for large national employers, public sector employers, mid-sized employers, small businesses, and individual consumers. As of December 31, 2020, UnitedHealthcare Employer & Individual provided access to medical services for 26.2 million people on behalf of its customers and alliance partners, including employer customers, serving people across all 50 states, the District of Columbia and majority U.S. territories. Products are offered through affiliates licensed as insurance companies, health maintenance organizations (HMOs), or third-party administrators (TPAs). Large employer groups use self-funded arrangements where UnitedHealthcare Employer & Individual earns a service fee. Smaller employer groups and individuals are likely to purchase risk-based products as they are less willing or unable to bear a potential liability for health care expenditures.
Through its risk-based product offerings, UnitedHealthcare Employer & Individual assumes the risk of both medical and administrative costs for its customers in return for a monthly premium, which is typically a fixed rate per individual served for a one-year period. When providing administrative and other management services to customers that elect to self-fund the health care costs of their employees and employees’ dependents, UnitedHealthcare Employer & Individual receives a fixed monthly service fee per individual served. These customers retain the risk of financing medical benefits for their employees and employees’ dependents, while UnitedHealthcare Employer & Individual provides services, such as coordination and facilitation of medical and related services to customers, consumers and health care professionals, administration of transaction processing and access to a contracted network of physicians, hospitals and other health care professionals, including dental and vision.
UnitedHealthcare Employer & Individual distributes its products through consultants or direct sales in the larger employer and public sector segments. In the smaller group segment of the commercial marketplace, UnitedHealthcare Employer & Individual’s distribution system consists primarily of direct sales and sales through collaboration with brokers and agents. UnitedHealthcare Employer & Individual also distributes products through wholesale agents or agencies that contract with health insurance carriers to distribute individual or group benefits and provide other related services to their customers. In addition, UnitedHealthcare Employer & Individual distributes its products through professional employer organizations, associations and through both multi-carrier and its own proprietary private exchange marketplaces. UnitedHealthcare Employer & Individual’s product portfolio offers employers a continuum of benefit designs, price points and approaches to consumer engagement, which provides the flexibility to meet their coverage needs.
UnitedHealthcare Employer & Individual’s major product families include:
Consumer Engagement Products: Consumer engagement products couple plan design with financial accounts to increase individuals’ responsibility for their health and well-being. This suite of products includes high-deductible consumer-driven benefit plans, which include health reimbursement accounts, health savings accounts and consumer engagement services, such as personalized behavioral incentive programs, consumer education and other digital offerings. The company also offers and is developing various consumer-centric products aligning with the needs and financial means of its customers, while engaging individuals in managing their health.
Traditional Products: Traditional products include a range of medical benefits and network options, and offer a spectrum of covered services, including preventive care, direct access to specialists and catastrophic protection.
Clinical and Pharmacy Products: UnitedHealthcare Employer & Individual offers a suite of clinical and pharmacy care services products, which complement its service offerings by improving quality of care, engaging consumers and providing cost-saving options. Consumers served by UnitedHealthcare Employer & Individual could access clinical products that help them make health care decisions and use of their medical benefits, which contribute to improved health and lowered medical expenses.
UnitedHealthcare Employer & Individual’s comprehensive and integrated pharmacy care services promote lower costs by using formulary programs to produce better unit costs, encouraging consumers to use drugs offering improved value and outcomes, helping consumers take actions to improve their health and supporting the appropriate use of drugs based on clinical evidence through physician and consumer education programs.
Each medical plan has a core set of clinical programs embedded in the offering, with additional services available depending on offering type (risk-based or self-funded), line of business (e.g., small business, key accounts, public sector, national accounts or individual consumers) and clinical need. UnitedHealthcare Employer & Individual’s clinical programs include wellness programs; decision support; utilization management; case and disease management; complex condition management; on-site programs, including biometrics and flu shots; incentives to reinforce positive behavior change; mental health/substance use disorder management; and employee assistance programs.
Specialty Offerings: Through its network, UnitedHealthcare Employer & Individual delivers dental, vision, hearing and other specialty benefits, including accident protection, critical illness, disability and hospital indemnity offerings, using an integrated approach in private and retail settings.
UnitedHealthcare Medicare & Retirement
UnitedHealthcare Medicare & Retirement provides health and well-being services to individuals age 50 and older, addressing their needs for preventive and acute health care services, as well as services dealing with chronic disease and other specialized issues common among older people. UnitedHealthcare Medicare & Retirement is dedicated to serving this senior market segment, providing products and services in all 50 states, the District of Columbia and most U.S. territories. UnitedHealthcare Medicare & Retirement has distinct pricing, underwriting, clinical program management and marketing capabilities dedicated to health products and services in this market.
UnitedHealthcare Medicare & Retirement offers a selection of products that allow people choice in obtaining the health coverage and services they need as their circumstances change. UnitedHealthcare Medicare & Retirement is positioned to serve seniors who find that affordable, network-based care provided through Medicare Advantage plans meets their unique health care needs. For those who prefer traditional fee-for-service Medicare, UnitedHealthcare Medicare & Retirement offers both Medicare Supplement and Medicare Prescription Drug Benefit (Medicare Part D) programs that supplement their government-sponsored Medicare by providing additional benefits and coverage options. UnitedHealthcare Medicare & Retirement services include care management and health system navigator services, clinical management programs, nurse health line services, 24-hour access to health care information, access to discounted health services from a network of care providers and administrative services.
UnitedHealthcare Medicare & Retirement has distribution capabilities and experience, including direct marketing to consumers on behalf of its key clients, including AARP, a membership organization dedicated to the needs of people age 50 and over, and state and U.S. government agencies. Products are also offered through agents, employer groups and digital channels. UnitedHealthcare Medicare & Retirement’s major product categories include:
Medicare Advantage: UnitedHealthcare Medicare & Retirement provides health care coverage for seniors and other eligible Medicare beneficiaries primarily through the Medicare Advantage program administered by the Centers for Medicare & Medicaid Services (CMS), including Medicare Advantage HMO plans, Preferred Provider Organization (PPO) plans, Point-of-Service plans, Private-Fee-for-Service plans and Special Needs Plans (SNPs). Under the Medicare Advantage program, UnitedHealthcare Medicare & Retirement provides health insurance coverage in exchange for a fixed monthly premium per member from CMS plus, in various cases, monthly consumer premiums. Premium amounts received from CMS vary based on the geographic areas in which individuals reside; demographic factors, such as age, gender and institutionalized status; and the health status of the individual. Medicare Advantage plans are designed to compete at the local level, taking into account consumer and care provider preferences, competitor offerings, the company’s quality and cost initiatives, its historical financial results and the long-term payment rate outlook for each geographic area. UnitedHealthcare Medicare & Retirement served 5.7 million people through its Medicare Advantage products as of December 31, 2020.
UnitedHealthcare Medicare & Retirement’s senior-focused care management model operates at a medical cost level below traditional Medicare, while helping seniors live healthier lives. The company focusing on digital and physical care resources in the home, expanding its concierge navigation services and enabling the home as a safe setting of care. For example, through its HouseCalls program, nurse practitioners performed approximately 1.7 million preventive care visits in 2020 to address unmet care opportunities and close gaps in care. The company’s Navigate4Me program provides a single point of contact and a direct line of support for individuals as they go through their health care experiences. For high-risk patients in certain care settings and programs, UnitedHealthcare Medicare & Retirement uses proprietary, automated medical record software and digital therapeutics for remote monitoring enabling clinical care teams to capture and track patient data and clinical encounters, creating a set of care information bridging across home, hospital and nursing home care settings. Proprietary predictive modeling tools help identify people at high risk and enable care managers to create individualized care plans to help them obtain the care.
Medicare Part D: UnitedHealthcare Medicare & Retirement provides Medicare Part D benefits to beneficiaries throughout the United States and its territories through its Medicare Advantage and stand-alone Medicare Part D plans. The stand-alone Medicare Part D plans address a spectrum of people’s needs and preferences for their prescription drug coverage, including prescription options. Each of the plans includes the majority of the drugs covered by Medicare and provides varying levels of coverage to meet the needs of Medicare beneficiaries. As of December 31, 2020, UnitedHealthcare enrolled 9.2 million people in the Medicare Part D programs, including 4.0 million individuals in stand-alone Medicare Part D plans, with the remainder in Medicare Advantage plans incorporating Medicare Part D coverage.
Medicare Supplement: UnitedHealthcare Medicare & Retirement is serving 4.5 million seniors nationwide through various Medicare Supplement products in association with AARP. UnitedHealthcare Medicare & Retirement offers a range of supplemental products. These products cover various levels of coinsurance and deductible gaps to which seniors are exposed in the traditional Medicare program.
UnitedHealthcare Community & State
UnitedHealthcare Community & State serves state programs caring for the economically disadvantaged, the medically underserved and those without the benefit of employer-funded health care coverage, typically in exchange for a monthly premium per member from the state program. UnitedHealthcare Community & State’s primary customers oversee Medicaid plans, including Temporary Assistance to Needy Families; Children’s Health Insurance Programs (CHIP); Dual SNPs (DSNPs); Long-Term Services and Supports (LTSS); Aged, Blind and Disabled; and other federal, state and community health care programs. As of December 31, 2020, UnitedHealthcare Community & State participated in programs in 31 states and the District of Columbia, and served 6.6 million people; including approximately 1.1 million people through Medicaid expansion programs in 16 states under the Patient Protection and Affordable Care Act.
States using managed care services for Medicaid beneficiaries select health plans by using a formal bid process or by awarding individual contracts. Various factors are considered by UnitedHealthcare Community & State when choosing programs for participation, including the state’s commitment of support for its Medicaid managed care program in terms of service; the eligible population base, both immediate and long term; and the structure of the projected program. UnitedHealthcare Community & State works with its state customers to advocate for actuarially sound rates, commensurate with medical cost trends.
These health plans and care programs are designed to address the needs of the populations they serve, including the chronically ill, people with disabilities and people with a higher risk of medical, behavioral and social conditions. UnitedHealthcare Community & State administers benefits for the needs of children, pregnant women, adults, seniors and those who are institutionalized or are nursing home eligible. These individuals often live in medically underserved areas and are less likely to have a consistent relationship with the medical community or a care provider. They also often face significant social and economic challenges.
UnitedHealthcare Community & State leverages the national capabilities of the company’s locally, supporting care management, strong regulatory partnerships, administrative efficiency, improved clinical outcomes and the ability to adapt to a changing national and local market environment. UnitedHealthcare Community & State coordinates resources among family, physicians, other health care providers, and government and community-based agencies and organizations to facilitate care and often addresses other social determinants affecting people’s health status and health system usage.
Approximately 75% of the people in state Medicaid programs are served by managed care, but this population represents approximately 50% of total Medicaid spending. UnitedHealthcare Community & State’s business development opportunities include entering fee-for-service markets converting to managed care; and growing in existing managed care markets, including state expansions to populations with needs requiring various models of care, including DSNP and LTSS programs. The company’s offerings to state expansion cover medically complex populations, including integrated care management of physical, behavioral, long-term care services and supports, and social services by applying data analytics and community-based collaboration.
UnitedHealthcare Community & State continues to evolve its clinical model to improve quality and the clinical experience for the people it serves. The model enables UnitedHealthcare Community & State to identify the people who could benefit from more coordinated care.
UnitedHealthcare Global serves 7.6 million people with medical and dental benefits, typically in exchange for a monthly premium per member, residing principally in Brazil, Chile, Colombia and Peru, as well as in 150 other countries. UnitedHealthcare Global serves multinational and local businesses, governments, insurers and individuals and their families through health insurance plans for local populations, care delivery services, benefit plans and risk and assistance solutions. UnitedHealthcare Global offers health care delivery in the company’s principal markets through approximately 50 hospitals, and 200 outpatient and ambulatory clinics and surgery centers to UnitedHealthcare Global members and consumers served by the external payer market.
Federal Laws and Regulation
CMS regulates the company’s UnitedHealthcare businesses and certain aspects of its Optum businesses. The use and disclosure of individually identifiable health data by the company’s businesses is also regulated in some instances by other federal laws, including the Gramm-Leach-Bliley Act (GLBA) or state statutes implementing GLBA.
The Employee Retirement Income Security Act of 1974, as amended (ERISA), regulates how the company’s services are provided to or through certain types of employer-sponsored health benefit plans. Regulations established by the U.S. Department of Labor subject the company to additional requirements for administration of benefits, claims payment and member appeals under health care plans governed by ERISA.
State Laws and Regulation:
The company’s various business activity is subject to other health care-related regulations and requirements, including PPO, Managed Care Organization, utilization review, TPA, pharmacy care services, durable medical equipment or care provider-related regulations and licensure requirements.
UnitedHealthcare Community & State and certain of the company’s Optum businesses are subject to regulation by state Medicaid agencies that oversee the provision of benefits to its Medicaid and CHIP beneficiaries and to the company’s dually eligible (for Medicare and Medicaid) beneficiaries.
Pharmacy and Pharmacy Benefits Management (PBM) Regulations
The company’s various pharmacies must also register with the U.S. Drug Enforcement Administration and individual state controlled substance authorities to dispense controlled substances.
Consumer Protection Laws
Certain of the company’s businesses participate in direct-to-consumer activities and are subject to regulations applicable to on-line communications and other general consumer protection laws and regulations, such as the Federal Tort Claims Act, the Federal Postal Service Act, and the Federal Trade Commission’s Telemarketing Sales Rule.
Optum Bank is subject to regulation by federal banking regulators, including the Federal Deposit Insurance Corporation, which performs annual examinations to ensure that the bank is operating in accordance with federal safety and soundness requirements; and the Consumer Financial Protection Bureau, which might perform periodic examinations to ensure that the bank is in compliance with applicable consumer protection statutes, regulations and agency guidelines.
Optum Bank is also subject to supervision and regulation by the Utah State Department of Financial Institutions, which carries out annual examinations to ensure that the bank is operating in accordance with state safety and soundness requirements and performs periodic examinations of the bank’s compliance with applicable state banking statutes, regulations and agency guidelines.
In addition, the company’s non-U.S. businesses and operations are subject to the U.S. laws that regulate the conduct and activities of the U.S.-based businesses operating abroad, such as the Foreign Corrupt Practices Act, which prohibits offering, promising, providing or authorizing others to give anything of value to a foreign government official to obtain or retain business or otherwise secure a business advantage.
Intellectual Property Rights
The company has obtained trademark registration for the UnitedHealth Group, Optum and UnitedHealthcare names and logos. The company owns registrations for certain of its other trademarks in the United States and internationally.
UnitedHealth Group Incorporated was founded in 1974. The company was incorporated in 1977 in Minnesota.