Employer funding & risk protection—not the funding model for every market below.
Risk-bearing stop-loss carriers
MGUs & specialty intermediaries
Captives & risk programs
Health Plans Markets & coverage—not infrastructure functions
Employer / commercial
Employer + employee funded. Fully insured or self-funded / ASO.
Challenger employer plans
Individual / ACA
Individual premiums; subsidies for eligible marketplace members.
Medicare Advantage
Private Medicare plans. CMS payments + applicable member premiums.
Medicaid / CHIP managed care
State contracts, funded jointly by states and the federal government.
The Blues: selected major organizations & regional licensees
A cross-market family of independent licensees—not a fifth plan market, and not all owned by Anthem / Elevance.
HCSC’s five Blues: Illinois, Montana, New Mexico, Oklahoma and Texas. Cambia pairs show affiliation. Regional footprints and product availability differ.
Companies repeat across markets where relevant. Commercial includes both employer and individual coverage; the separate columns make the buying channels visible. D-SNPs sit within Medicare Advantage and coordinate with Medicaid.
Shared Plan Infrastructure Functions used across plan markets; no single vendor supplies every function to every plan
Administration / Core Systems
TPA / ASO services · carrier-owned
Independent administration & platforms
Core software · TriZetto, HealthEdge & peers
The software platform is not necessarily the TPA operating it.
Pharmacy Benefits · PBMs & Adjacent Services
Payer-owned PBMs
Other established & challenger PBMs
Pharmacy benefits optimization / PBO
Pharmacy administration technology
Claims / Payment
Claims, pricing & payment rails
Payment integrity / claims accuracy
Member funding & payments
Provider Network
Broad provider access
Direct contracting, quality & COEs
Clinical Integration
Group-owned care & services
Highmark Health is the parent of both Highmark and AHN. Internal plan care management appears separately below.
Pharmacy Network & Specialty
Dispensing & pharmacy networks
Specialty drug management & carve-outs
Prescription infrastructure
Care Management / Navigation / Digital Care
Plan-branded care management
Internal capabilities—not separate Optum-style subsidiaries. Selected examples, not a complete inventory.
Navigation & integrated care
Virtual, chronic & behavioral care
Care programs are not automatically risk-bearing VBC businesses.
Benefit administration & non-medical support. Availability depends on the plan and contract.
TPA = third-party administrator · ASO = administrative services only · PBM = pharmacy benefit manager · MGU = managing general underwriter · COE = center of excellence
Value-Based Care Care delivery, risk partnerships & enabling technology
VBC is a payment and care-delivery model—not another type of insurance. It spans Medicare Advantage, Original Medicare ACOs, Medicaid and commercial contracts.
Primary care / integrated delivery
Physician enablement / ACOs / risk partnerships
Specialty & complex-population care
VBC data / analytics / clinical software
Risk varies by contract: shared savings, downside risk, capitation or fees. A software vendor or care manager is not automatically a risk-bearing provider.
New additions: pharmacy, payer care management and MA enablement
PBM versus adjacent services:RxBenefits describes its PBO model: contracting, independent clinical management and service around PBM arrangements. It is not presented as interchangeable with the contracted PBM. Navitus, MedImpact, Liviniti, EmpiRx and AffirmedRx belong in the PBM universe. Navitus is co-owned by SSM Health and Costco; its portfolio includes Lumicera specialty pharmacy and Archimedes specialty-drug management. RxSense belongs in pharmacy technology, not automatically in the full-service PBM bucket.
Aetna, Highmark, HCSC and Molina do have care-management capabilities.Aetna One is plan-branded care management, not a separate provider conglomerate. Highmark Health is the parent of the Highmark insurer and AHN provider system; the insurer is not shown as AHN’s parent. HCSC owns CareAllies and also has internal clinical management. Molina’s 2025 Form 10-K describes care and population management, Medicaid, Medicare and Marketplace operations. Molina appears in all three relevant plan markets—not employer coverage by default. Its outsourced PBM relationship does not imply PBM ownership. Omission from any selective bucket does not establish that a company lacks that capability.
Insurance versus enablement:Essence Healthcare, SCAN and Healthfirst are shown as plans. Lumeris, Wellvana and Vytalize sit in value-based-care enablement. Essence and Lumeris are closely connected, but plan operations and enablement remain different functions. Molina’s stated 2027 traditional MA-PD exit is a future change relative to this 2026 map; dual-eligible coverage is a separate consideration.
VC exit review: acquisitions, IPOs and current operating brands
This expansion screens venture-backed healthcare exits for relevance to health plans, care access, navigation and clinical programs. It is not a ranking of investment returns. An IPO or acquisition is a transaction event—not proof that investors realized a gain. Current company placement takes precedence over counting historical brands twice.
Amazon → One Medical. Primary care and senior VBC delivery; the former Iora business is noted under Senior Health, not counted again as an independent company.
Separate public businesses in clinical programs. Their digital-care services do not automatically make every contract risk-bearing VBC. The technology-led cohort includes public growth companies.
Mosaic → Castlight, via apree, in navigation. Mosaic also appears with apree, Vera, CareMore and Millennium. Mosaic’s portfolio is an Elevance / CD&R joint venture—not simply an entirely owned Elevance subsidiary.
Reviewed September 15, 2026. New marks are sourced from company sites; One Medical’s SVG is from Wikimedia Commons. Original logo sources are recorded with the assets. Pure biotech, devices and unrelated provider-software exits are outside this payer-centered scope.
Why markets, functions and value-based care are separate
A plan market answers “who is covered and who funds coverage?” Employer, individual / ACA, Medicare Advantage and Medicaid managed care are different buying and funding arrangements. They are not additional layers on top of a TPA or PBM. Original Medicare is public coverage; its ACOs are not private MA insurance plans. CMS explains the ACO distinction.
A function answers “what work is being done?” Administration, claims accuracy, pharmacy management, provider access and care management can serve several markets. A TPA supplies operating services; a core-platform vendor supplies software that an insurer or TPA can run. Cognizant’s TriZetto Facets supports multiple payer lines of business. Cotiviti’s payment integrity and risk / quality capabilities explain its repeated placement.
Value-based care answers “how are providers paid and held accountable?” The VBC section separates care delivery from physician enablement, specialty / complex care, and software. Businesses can combine these roles, and risk-bearing arrangements vary by contract. Category dimensions are kept separate, but companies are deliberately not mutually exclusive.
How these pieces produce a health plan
The employer and its advisor choose the benefits, funding model and service partners. In a self-funded plan, the employer pays the claims; a TPA operates eligibility, claims and member service, while a stop-loss insurer covers specified large losses. The provider network supplies contracted access, the PBM manages pharmacy benefits, and care and payment services plug into those functions. A carrier can bundle much of this into one contract.
A TPA runs the plan’s administration. Being the administrator does not automatically make it the insurer that bears the claims risk. The map deliberately lets an integrated business appear in every function it performs.
Revenue and take rates: how to read the money flows
There is no single comparable “take rate” across this map. For an employer plan, use the total plan budget as a common denominator, then distinguish claims flowing through a company from the fees and margin it retains. Adding insurer revenue, PBM revenue and provider revenue will count some of the same dollars multiple times.
Layer
Revenue model
Useful denominator
Broker / advisor
Commission or employer-paid consulting fee
Commissionable premium or total plan budget
Carrier / stop-loss
Premium; claims and expenses consume most of it
That policy’s premium; loss ratio is not a profit margin
MGU / captive
Underwriting / management fees; possible profit participation
Managed premium, with risk-bearing income separated
TPA / ASO
Per employee / member per month, plus contracted service fees
Administrative revenue divided by total plan spend
Core software / analytics
Subscriptions, licenses, implementation and service fees
Members administered or contracted software / services spend
PBM / pharmacy
Admin fees, dispensing margin and contract-dependent rebate / spread economics
Net pharmacy spend after rebates; separate pass-through drug cost
Network / payments / clinical
Access fees, transaction fees, subscriptions, case rates or shared savings
Relevant claims volume or total plan spend, stated explicitly
Medicare Advantage plan
CMS payments, affected by risk adjustment and quality rules, plus applicable member premiums
Total plan revenue for the covered population; not an administrative “take rate”
Attributed medical spend or capitation, with retained fees and margin separated
Medicare pays MA plans for covered beneficiaries; the plan then funds care and operations. An MA insurer’s revenue and its risk-bearing provider’s revenue can contain the same dollars. Exact amounts and percentages require a defined population, accounting basis and contracts.
Current ownership:HealthSpring is part of HCSC, following its acquisition of Cigna’s Medicare business in 2025. CVS Health Care Delivery includes Oak Street and Signify. Counterpart Health is Clover’s technology and services business.
Expansion checked September 14–15, 2026. New logos come from company sites except Molina’s logo (CompaniesLogo) and the Blue Cross NC logo displayed on partner Strive Health’s site. Asset provenance is retained locally. Current Cognizant branding is shown beside a textual TriZetto product label, rather than presenting the provider-RCM business’s logo as its payer core system.
What is still outside this map?
Useful next expansions include deeper behavioral-health network coverage, home health / post-acute / long-term services, transportation and food-as-medicine specialists, delegated credentialing, interoperability / data exchange, actuarial and regulatory operations, provider revenue-cycle management, dental / vision / hearing carriers, and the broader reinsurer layer. Original Medicare contractors (MACs), stand-alone Part D, Medigap and PACE also deserve distinct sections; they should not all be folded into Medicare Advantage.
This is a payer-centered market map, not a complete healthcare-industry directory. It does not attempt to list every hospital, physician group, local ACO or regional Blues licensee.
Sources and company notes
Taxonomy starting point: Julie Yoo, a16z, “The Great Health Plan Replacement,” September 10, 2026, and the accompanying Challenger Health Plan Stack.
Judi Rx is the current name of Capital Rx; Judi Health also supplies medical-benefit administration and software.
Aradigm supplies a cell-and-gene-therapy carve-out; it is shown under specialty rather than treated as a full-service PBM.
Logo links open the corresponding company website. All marks belong to their respective owners; inclusion does not imply endorsement.
Classification and expanded-market sources
AI / tech startup is an editorial grouping of the original a16z challenger cohort plus selected technology-led challengers. It includes growth-stage businesses and does not mean that every company is AI-native. The a16z marker records inclusion in the supplied graphic, not an investment relationship. Incumbent means an established carrier, brokerage, administrator, service platform or specialist program manager, including operating brands owned by those groups. It does not mean “does not use AI.” These are market-position labels, not regulatory categories or a founding-year cutoff.
Captives:ParetoHealth and Roundstone are established benefits-captive/program managers. Tokio Marine HCC also supplies captive stop-loss, so it repeats in that bucket. A captive manager, the employer-owned captive, and the stop-loss insurer are distinct parties.
Sources checked September 13, 2026. Company websites provide the new logo assets except Symetra, whose displayed logo comes from Icon Logo Vector. All marks remain the property of their owners.
