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Humana
Humana
Humana
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Humana Inc. is an American for-profit health insurance company based in Louisville, Kentucky. In 2024, the company ranked 92 on the Fortune 500 list,[2] which made it the highest ranked (by revenues) company based in Kentucky.[citation needed] It is the fourth largest health insurance provider in the U.S.[3]

Key Information

History

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1961–1983: Nursing homes and hospitals

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Lawyers David A. Jones Sr. and Wendell Cherry founded a nursing home company in 1961.[4] The company, known in 1968 as Extendicare Inc., became the largest nursing home company in the United States. In 1972, Jones and Cherry sold the nursing home chain to purchase hospitals.[5]

In 1974, the partners changed the corporate name to Humana Inc.[5] The name was meant to change public perception from 'warehousing' or indifferently treating people to providing a higher level of human care and, by extension, more humane care.[6] It grew in the following years, both by business and in 1978 through the takeover of American Medicorp Inc.,[7] which doubled the company's size, and grew into the world's largest hospital company in the 1980s.[8] During this period, Humana developed the double corridor model for hospital construction. This design minimized the distance between patients and nurses by placing nursing support services in the interior of the building with patient rooms surrounding the perimeter.[citation needed]

1984–present

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As the American health care system changed in the 1980s, "one of its hospitals in Arizona lost a contract with the largest health-maintenance organization in the area [and] Humana created its own health insurance plan."[5]

In 1993, Humana had become the largest hospital operator in the country, owning 77 hospitals.[citation needed] Humana executives spun off hospital operations from health insurance operations to create Galen Health Care. The following year they sold the 73 hospitals of Galen Health Care Inc. to Nashville-based Columbia Hospital Corporation of America for $3.4 billion.[5]

In 1998, one year after Jones had stepped aside as CEO, United Healthcare made an unsuccessful attempt to acquire Humana.[5] Humana pulled out of the acquisition after United stock dropped $2.9 billion in value.[9] In 2001, Humana was a cofounder of Avality.[10]

In 2005, Humana entered into a business partnership with Virgin Group, offering financial incentives to members for healthy behavior, such as regular exercise.[11]

On November 16, 2006, the Centers for Disease Control and Prevention (CDC) and Humana Inc. partnered to expand on traditional private-sector approaches to population health management.[12]

In 2010, Humana bought Texas-based Concentra Inc., which owns urgent-care and physical therapy centers, for $790 million, effectively returning to healthcare services.[5] In May 2011, Humana announced it would be using mobileStorm to transmit protected health information to patients.[13]

In March 2015, Humana announced the sale of Concentra to private equity firm Welsh, Carson, Anderson & Stowe and Select Medical Holdings Corporation for about $1 billion, with proceeds to fund a "$2 billion share buyback program and other corporate spending."[14]

In July 2015, Aetna announced that it would acquire Humana for $37 billion in cash and stock (approximately $230 a share at that time). Aetna and Humana shareholders would own 74% and 26% of the new combined company, however the merger was blocked by a federal judge in January 2017.[15][16] In February 2017, Aetna Inc. and Humana Inc. quashed a $34 billion merger agreement after judges ruled against the merger for a second time.[17]

In July 2018, Humana joined two private equity firms in the acquisition of Kindred Healthcare. The deal provided Humana with a 40% stake in the company's home health, hospice and community care businesses, called "Kindred at Home," for approximately $800 million.[18][19] In August 2018, Humana announced the creation of a digital health and analytics division called Humana Studio H.[20]

In December 2019, the company announced it would acquire Enclara Healthcare from Consonance Capital Partners and Enclara management.[21]

In 2021, Susan Diamond, formerly occupying an interim position, was announced to be the new permanent CFO. Her appointment to the position comes with the company's focus being turned towards the home healthcare business, acquiring in April of the same year a 60% stake in Kindred at Home, an in-home care and hospice business.[22][23][24]

In April 2022, it was announced Humana would sell a 60% interest of its Kindred at Home division to the private investment company, Clayton, Dubilier & Rice, for US$2.8 billion.[25]

In February 2023, Humana announced they were exiting the employer-based commercial group insurance market. [26]

Corporate affairs

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Sponsorship

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Humana is the presenting sponsor of the Grand Ole Opry[27] and the National Senior Games.[28]

Since 1979, Humana has been a principal sponsor of the annual Humana Festival of New American Plays in Louisville, Kentucky.[29]

LPGA player Nancy Scranton was a spokesperson for Humana.[30] In the past, PGA Tour player David Toms' David Toms Foundation has partnered with the Humana Foundation to provide grants to several children's charities in New Orleans.[31] Humana is the official health benefits provider of the PGA Tour and Champions Tour.[citation needed]

The Humana Distaff Handicap is a Grade 1 race for thoroughbred fillies and mares, four-years-old and up. The race is run each spring on Kentucky Derby day at Churchill Downs and set at a distance of 7 furlongs for a purse of $250,000.[citation needed]

Humana Military Healthcare Services

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In 1993, Humana founded Humana Military Healthcare Services (HMHS) as a wholly owned subsidiary.[5] They were awarded their first TRICARE contract in 1995, and began serving military beneficiaries in 1996.[32]

From 2004 to 2009, HMHS was the managed care contractor for the Department of Defense Military Health System TRICARE South Region.

In 2009, HMHS' Managed Care Support Contract was awarded to United Military and Veterans Services, a subsidiary of UnitedHealth Group. HMHS protested that decision and the Government Accountability Office upheld the protest in late 2009.[33]

In 2011, HMHS regained the five-year contract to administer medical benefits to military members and families in the South region, a contract worth $23.5 billion.[5] In 2018, this was moved to the new TRICARE East region during the TRICARE regional realignment.

On December 22, 2022, the Department of Defense announced the award of the managed care support contract for the TRICARE East Region to Humana Military.[34]

[edit]

Humana filed a lawsuit in August 2019, alleging that 37 defendants engaged in a “far-reaching conspiracy” to “blatantly fix the price” of generic drugs. This follows a similar smaller lawsuit from October 2018.[35]

Controversy

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In 1987, Humana sued NBC over a story line in the television medical drama St. Elsewhere in which the hospital was to be sold to a for-profit medical corporation and renamed "Ecumena", with subsequent changes to the hospital, both positive and negative, emanating from that change. The company claimed that the program infringed on the Humana trademark.[36] Humana failed to block the airing of the show,[36] but was successful at forcing NBC into showing a disclaimer at the beginning of the September 30 episode saying that the drama had no connection whatsoever with Humana.[37]

On May 30, 1996, Linda Peeno, a physician who was contracted to work for Humana for nine months, testified before Congress as to the downside of managed care. Peeno said she was effectively rewarded by her employer for causing the death of a patient, because it saved the company a half-million dollars. Peeno stated that she felt the "managed care" model was inherently unethical.[38]

In 1999, season one of Michael Moore's TV series The Awful Truth reported on Humana refusing to pay for a diabetic patient with pancreatic failure needing a transplant. The man's policy stated it covered all of his diabetes-related expenses, but another section of the policy stated that it did not cover organ transplants. Moore conducted a fake funeral on the front steps of the Humana building, and three days later Humana changed its policy and authorized the man's treatment.[39]

Michael Moore's 2007 documentary Sicko used the video of Linda Peeno's testimony.[40] On June 28, 2007, Humana declared that Peeno was never a Humana "associate" (permanent, full-time employee), but rather a "part-time contractor." Humana disputed portions of her Congressional testimony by saying that because the patient's healthcare plan did not cover heart transplants, denial of coverage was valid.[41]

On September 21, 2009, the U.S. Dept. of Health and Human Services opened an investigation into Humana for sending flyers to Medicare recipients that the AARP characterized as deceptive.[42] The mail was made to appear to contain official information about Medicare Advantage and prescription drug benefit information, but instead alleged that core Medicare benefits could be cut by the Obama administration's healthcare reform,[43] a claim refuted by John Rother, AARP's executive vice president.[44] Douglas Elmendorf, the head of the Congressional Budget Office (CBO), supported the claim that Medicare benefits could be cut,[45] but his comments were in reference to just one of several congressional bills. CBO estimates of another healthcare reform bill found that changes to premiums would vary.[46] The Centers for Medicare and Medicaid Services instructed Humana to cease all such mailings to Medicare plan members pending an investigation.[43] HHS Secretary Kathleen Sebelius, in a letter to the insurance industry, threatened that bad actors may be excluded from new health insurance markets that were to open in 2014. Senate Republicans pointed out in a letter to Sebelius that a 1997 directive from the Centers for Medicare and Medicaid Services explicitly allowed HMOs to tell members about legislation and urge them to express opinions.[citation needed]

See also

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References

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[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Humana

View on Grokipedia
from Grokipedia
Humana Inc. is an American for-profit company headquartered in , that provides medical and specialty insurance products, with a primary focus on plans, alongside commercial group coverage and integrated healthcare services through its CenterWell division. Originally founded in 1961 by lawyers David A. Jones Sr. and Wendell Cherry as Extendicare Inc., a operator, the company expanded into management before pivoting to health insurance in the 1990s, becoming a entity ranked 92nd by revenue in 2024. Humana serves over 17 million total members, including approximately 5.8 million in plans as of June 2025, securing about 17% of national enrollment and dominating or co-dominating markets in numerous counties. Key achievements include pioneering consumer-centric health benefits and achieving high veteran-friendly employer ratings, while notable controversies encompass securities class-action litigation alleging misleading disclosures on utilization and risk adjustment from 2022 to 2024, as well as a failed federal challenge to its lowered 2025 plan star ratings, which could reduce bonus payments and affect membership retention.

History

Founding and nursing home operations (1961–1974)

Humana was founded in 1961 in , by lawyers David A. Jones Sr. and Wendell Cherry as a operator initially named Extendicare Inc. (also referred to early on as Heritage House of America Inc.). The duo each invested $1,000, joined by four friends, to construct the company's first facility, capitalizing on the emerging demand for amid an aging population. The first Heritage House nursing home opened in 1962 on Liverpool Lane in Louisville, featuring 78 beds and marking the start of rapid expansion across , , and . By 1968, Extendicare had grown to over 40 facilities, establishing itself as the largest chain in the United States through organic development and stock sales. The enactment of Medicare and in the mid-1960s significantly accelerated this growth by reimbursing care for elderly and low-income patients, enabling further acquisitions and construction. Nursing home operations emphasized efficient, scalable care models, with Extendicare going public in 1968 to fund expansion; by 1970, it operated over 100 facilities nationwide. In 1971, the company acquired Hill Haven Corp., adding specialized skilled nursing services and bolstering its market dominance. However, recognizing saturation in the sector, Jones and Cherry began divesting nursing home assets in 1972 to pivot toward hospitals, completing the sale of the chain by that year while retaining focus on healthcare delivery efficiencies honed in long-term care. The company was renamed Humana Inc. in January 1974, signaling the formal end of its primary nursing home phase.

Hospital expansion and diversification (1974–1993)

In 1974, Extendicare Inc. restructured its operations by spinning off its nursing home business into a separate entity and renaming the hospital-focused division Humana Inc., marking a strategic pivot toward facilities. The company accelerated hospital development through a process, enabling the opening of approximately one new facility per month during the mid-1970s. This expansion incorporated the innovative double corridor model, which positioned patient rooms between parallel corridors—one for staff access and one for visitors—to reduce travel distances for nurses and improve . Humana's growth intensified in 1978 with the acquisition of American Medicorp Inc., the second-largest U.S. hospital chain at the time, which effectively doubled Humana's size and bolstered its network of owned and managed facilities. By the early , the company had established itself as one of the leading for-profit hospital operators, expanding through both organic builds and targeted purchases across the . Notable developments included the 1983 opening of Humana Hospital University in , at a cost of $73 million, and the 1984 implantation of the Jarvik-7 at Humana Hospital Audubon—the world's second permanent human recipient of the device. Diversification efforts complemented hospital expansion, as Humana entered prepaid plans in 1984 with Humana Plans, aimed at securing volume for its facilities despite initial setbacks from underpriced premiums. By the mid-1980s, Humana had grown into the world's largest operator, operating dozens of facilities and completing its 27-story in Louisville in 1985. The plans division achieved its first operating profit of $4 million in , signaling viability in precursors. By 1993, Humana operated 76 hospitals but faced pressures from regulatory changes and shifting industry dynamics, leading to the spin-off of these assets into the independent Galen Health Care Inc., which later merged with Columbia Hospital Corp. This divestiture allowed Humana to streamline operations amid rising costs and competition in hospital management.

Shift to managed care and health insurance (1994–2003)

In 1994, following the prior year's spin-off of its hospital operations into Galen Health Care—which was sold to Columbia/HCA for $3.4 billion—Humana completed its strategic pivot to by acquiring the Group Health Association HMO with 125,000 members and the Milwaukee-based CareNetwork HMO for $180 million, expanding its health plan footprint in key urban markets. This refocus on health maintenance organizations (HMOs) and preferred provider organizations (PPOs) aligned with industry trends toward cost containment through and provider networks, rather than direct ownership of care facilities. Membership growth accelerated in 1995 with the $650 million acquisition of EMPHESYS Financial Group, adding 1.3 million members and bringing Humana's total enrollment to 3.8 million, while revenues reached $4.7 billion primarily from premium income. However, profitability pressures emerged in 1996 amid rising medical costs and competitive bidding for employer contracts; Humana exited 13 unprofitable markets, including selling the recently acquired Group Health Association to at a $100 million loss, and recorded a $200 million pretax charge, resulting in of just $12 million. Rebound occurred in 1997 through acquisitions of Physician Corporation of America for $290 million plus $121 million in debt (adding 1.1 million members) and ChoiceCare Corporation for $250 million (250,000 members), driving revenues to $8.04 billion and net income to $173 million as Humana consolidated its position in commercial and Medicare HMO segments. In May 1998, Humana announced a $5.4 billion stock-swap merger with United HealthCare Corporation to form a 10.4 million-member giant, but the deal collapsed in August due to United's unexpected quarterly losses and a sharp decline in its stock value, amid broader regulatory scrutiny and antitrust concerns. The late 1990s managed care backlash, fueled by patient complaints over denied claims and provider restrictions, led to class-action lawsuits against Humana and peers for practices like capitation incentives that allegedly prioritized cost savings over care quality. Enrollment growth slowed industry-wide as consumers and employers shifted toward less restrictive PPO models, prompting Humana to refine its product mix by 2000 with acquisitions like CarePlus Health Plans to bolster Medicare HMO presence in high-growth areas such as . By 2003, premium revenues had climbed to approximately $9.6 billion from 1998 levels, but persistent challenges from medical loss ratios and regulatory pressures underscored the limits of pure HMO strategies without diversification.

Growth in Medicare Advantage and modern developments (2003–present)

Following the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which restructured the Medicare+Choice program into Medicare Advantage (MA) with improved payment benchmarks and risk adjustment mechanisms, Humana pivoted its strategy to prioritize MA expansion as a core growth driver. This shift capitalized on higher per-beneficiary payments to private plans compared to traditional fee-for-service Medicare, enabling Humana to offer supplemental benefits that attracted enrollment. By leveraging its managed care infrastructure, Humana rapidly scaled its MA offerings, transitioning from a diversified insurer to a dominant player in the senior market. Humana's MA enrollment surged alongside industry-wide growth, with the company's Medicare segment becoming its primary revenue source. In 2022, this segment accounted for 81% of Humana's annual revenue, predominantly from individual MA plans. By 2024, UnitedHealthcare and Humana collectively enrolled nearly half of all 32.9 million MA beneficiaries nationwide, underscoring Humana's market leadership despite competitive pressures. The firm's growth was fueled by organic expansion, targeted during open enrollment periods, and integration of coverage under Part D, which facilitated to MA. Key milestones included Humana's aggressive entry into Part D in 2006 to build a pipeline for MA conversions and its attempted $37 billion merger with announced in 2015, aimed at bolstering scale in MA and pharmacy benefits but blocked by antitrust regulators in 2017 due to concerns over reduced competition in MA markets. In the , Humana enhanced plan designs with extras like dental, vision, and hearing aids, aligning with CMS incentives for higher star ratings that influence bonuses and rebates. By 2025, 99% of Humana's individual MA plans included vision coverage, 98% dental, and over 97% hearing services, reflecting a to differentiate amid rising MA penetration exceeding 50% of eligible beneficiaries. Modern developments have introduced challenges amid maturing market dynamics. Post-2020, Humana grappled with elevated utilization and medical loss ratios following deferred care during the , contributing to profitability pressures despite growth to $32.1 billion in Q1 from higher per-member premiums. Enrollment growth slowed industry-wide, with Humana reporting a net decrease of about 297,000 MA members from 2024 to , partly due to strategic exits from underperforming plans and a drop in average star ratings to 3.5 for , which reduced bonus eligibility. The company unsuccessfully challenged CMS's ratings in federal court, arguing methodological flaws could cost billions in , highlighting tensions over opaque metrics that affect 70%+ of Humana's individual MA enrollment. Regulatory scrutiny intensified on denials and payment accuracy, with audits revealing overpayments in some MA plans, though Humana maintained these practices ensure fiscal sustainability against risk selection incentives. Looking ahead, Humana affirmed adjusted EPS guidance of $16.25 while emphasizing cost controls and selective growth in high-rated plans.

Business Model and Operations

Core products and services

Humana's primary health insurance products consist of plans, which integrate coverage for hospital (Part A) and medical (Part B) services with additional benefits such as dental, vision, hearing, and prescription drugs in many cases. These plans are offered in various models, including Health Maintenance Organizations (HMOs) like Humana Gold Plus and Preferred Provider Organizations (PPOs), with options for dual-eligible plans (D-SNPs) that coordinate benefits for individuals qualifying for both Medicare and . The company also provides standalone prescription drug plans (PDPs) and policies to cover out-of-pocket costs not addressed by Original Medicare. In 2023, Humana announced its exit from the commercial employer group and individual markets over 18 to 24 months, redirecting focus to government-sponsored programs like Medicare and Medicaid-integrated offerings to streamline operations amid rising medical costs in non-Medicare segments. Complementing its insurance products, Humana operates pharmacy services through CenterWell Pharmacy, which includes mail-order delivery, specialty pharmacy for complex medications, and retail locations integrated with sites, serving as the preferred option for many Humana plan members to reduce costs via . Additionally, CenterWell Senior provides clinic-based services tailored to Medicare-eligible patients, emphasizing preventive care, management, and coordination with home health and behavioral health resources, with locations offering extended physician time and on-site pharmacy access. Wellness initiatives, such as the Go365 program, support members with rewards-based activities for cessation, maternity, and cancer management, though these are ancillary to core insurance and pharmacy functions.

Focus on Medicare Advantage plans

Humana's (MA) plans, also known as Medicare Part C, represent the core of its operations, providing an alternative to traditional Medicare by bundling Parts A, B, and often D coverage through private networks. These plans emphasize coordinated care models, including health maintenance organizations (HMOs) and preferred provider organizations (PPOs), with offerings available in 46 states and Washington, D.C., covering approximately 85% of U.S. counties as of 2026 plan designs. Humana reported approximately 5.5 million individual MA enrollees in 2024, though it anticipates a decline of about 550,000 members, or 10%, in 2025 due to factors such as elevated utilization and market adjustments. As the second-largest MA provider behind UnitedHealthcare, Humana holds significant market share, with 25% enrollment dominance in certain counties and leading positions in specialized segments like plans (SNPs). MA plans from Humana typically include supplemental benefits beyond Original Medicare, such as routine dental, vision, and hearing services, which became standard across all plans starting in 2026; $0 copays for unlimited in-network visits; and no-cost preventive services like vaccines, mammograms, colonoscopies, and prostate exams. These extras aim to address gaps in traditional Medicare, potentially reducing out-of-pocket costs for enrollees while incentivizing preventive care through network restrictions. However, plan availability and specifics vary by , with HMO options often limiting coverage to local networks for cost control, whereas PPO variants offer broader flexibility at higher premiums. Performance metrics for Humana's MA plans have faced headwinds, particularly in (CMS) Star Ratings, which evaluate quality on a 1-5 scale based on member experience, care coordination, and outcomes. In 2024, 94% of Humana's MA members were in 4-star or higher plans, but this fell sharply to about 25% in 2025 and stabilized at 20% (roughly 1.2 million members) for 2026, reflecting challenges in meeting CMS thresholds for rewards like bonus payments. Lower ratings stem from factors including appeals processes and data validation, prompting Humana to invest in operational fixes like enhanced member engagement and provider alignment. Regulatory and operational scrutiny has intensified around Humana's MA practices, including prior authorization denials and risk adjustment coding. A 2024 Senate report highlighted Humana's use of AI-driven tools to deny post-acute care requests, contributing to a 54% rise in long-term acute care denials from 2020 to 2022, which critics argue prioritizes profits over patient needs. Industry-wide, including Humana, MA plans have faced accusations of upcoding—intensifying diagnoses via home visits to inflate scores and secure higher CMS payments—resulting in an estimated $33 billion in extra 2021 payments from coding practices and $20.5 billion in overpayments to firms like Humana as of 2023 analyses. Projections suggest upcoding could lead to $600 billion in Medicare overpayments over the next decade, fueling calls for audits and clawbacks, as evidenced by Humana's ongoing legal challenges to CMS auditing rules. Despite these issues, empirical data indicate MA enrollees, including those in Humana plans, often experience lower overall costs and better access to extras compared to Original Medicare, though at higher taxpayer expense due to benchmark overpayments averaging 104% of equivalents.

Military healthcare and other segments

Humana Military, a subsidiary of Humana Inc., administers the TRICARE East Region health plan for the U.S. Department of Defense, providing managed care services to active duty service members, retirees, their families, and other eligible beneficiaries. The East Region encompasses 21 states, the District of Columbia, and U.S. territories in the eastern United States, serving over 2.7 million beneficiaries as of the contract's inception. Humana was awarded the initial TRICARE East contract in July 2016, valued at up to $16.1 billion over nine years, with responsibilities including claims processing, provider network management, and beneficiary support services. This contract was extended under a new agreement effective January 1, 2025, maintaining Humana Military as the regional contractor amid restructuring of TRICARE regions, though six states shifted to the West Region. The East program under Humana emphasizes coordinated care through a network of treatment facilities and providers, with Humana handling enrollment, authorizations, and via a dedicated call center operating 8 a.m. to 6 p.m. ET/CT on weekdays. Humana 's operations include portals for and providers to manage accounts, claims, and eligibility, alongside efforts to integrate and preventive care aligned with health priorities. under the has focused on network adequacy and cost control, though specific outcome metrics are reported through Department of Defense oversight rather than public Humana disclosures. Beyond military healthcare, Humana operates in the Group and Specialty segment, which encompasses employer-sponsored commercial insurance products, including medical, dental, and vision plans for large and small groups. This segment also includes administrative services only (ASO) arrangements and specialty benefits like life and disability coverage, serving businesses seeking cost-effective group coverage outside government programs. Humana offers individual and family health plans in select markets, though these represent a smaller portion of its portfolio compared to government-funded lines, with enrollment fluctuating based on Affordable Care Act marketplaces. Additionally, Humana participates in state-based Medicaid managed care contracts in limited geographies, providing coordinated services to eligible low-income populations, though it has scaled back in this area to prioritize higher-margin segments. These non-Medicare Advantage operations collectively contribute to diversified revenue, with the Group and Specialty segment reporting pretax income influenced by enrollment trends and utilization rates as of fourth-quarter 2024 results.

Pharmacy and wellness initiatives

Humana's operations are primarily conducted through CenterWell , which offers including mail-order delivery, retail access, specialty medications, and over-the-counter (OTC) benefits tailored to plan members. This division supports prescription fulfillment for plans, with formularies listing covered drugs and tools for prior authorizations and generic alternatives. Humana Solutions functions as its pharmacy benefit manager (PBM), handling drug pricing negotiations, formulary management, and rebate processing, holding approximately 8% of the U.S. PBM as of 2024. Key pharmacy initiatives include the Medication Therapy Management (MTM) program, a Medicare-mandated service providing comprehensive medication reviews to eligible members, aiming to optimize therapy, reduce adverse events, and improve adherence, particularly for those with multiple chronic conditions or high drug costs. CenterWell Specialty Pharmacy delivers targeted clinical outreach for complex conditions, such as oncology or rare diseases, including patient education and adherence monitoring. In 2025, Humana expanded pharmacy growth projections amid medical cost controls, reflecting integration with broader Medicare Advantage strategies. Patient assistance programs facilitate cost reductions through manufacturer copay cards, payment spreading, and low-income subsidies under the Low-Income Subsidy (LIS) or LI NET temporary coverage for dual-eligible beneficiaries. Wellness initiatives emphasize preventive care and behavioral incentives, with the Go365 program rewarding members for activities like exercise tracking, healthy eating, and wellness via points redeemable for gift cards or premiums discounts, available to Medicare and employer plan participants. SilverSneakers, included in most Humana plans, provides free gym memberships and fitness classes to adults aged 65 and older, focusing on strength, balance, and to combat age-related decline, with participation linked to lower healthcare utilization in studies of similar programs. Additional wellness efforts include the Humana Healthy Options Allowance, reimbursing members for OTC items like vitamins, pain relievers, and first-aid supplies up to specified annual limits on select plans. Programs address specific risks through tobacco cessation coaching, maternity support via HumanaBeginnings, and cancer care navigation, integrating digital tools for goal tracking and virtual coaching. Medicare Annual Wellness Visits, covered under Humana plans, enable personalized prevention plans based on health risk assessments, distinct from routine physicals. These initiatives align with value-based care by incentivizing engagement, though effectiveness varies by member participation rates reported in Humana's program data.

Financial Performance

Humana's revenue is overwhelmingly derived from premiums within its segment, which encompasses , , and military health programs. In fiscal year , premiums accounted for 96.2% of consolidated revenues, amounting to approximately $113.1 billion out of total revenues of $117.8 billion. The segment generated $113.8 billion in GAAP revenues for the year, up from $102.9 billion in 2023, reflecting its dominance in the company's topline. Within premiums, individual plans contributed the largest share at $88.0 billion, followed by state-based contracts and other programs at $10.9 billion, group at $7.7 billion, and stand-alone plans at $3.1 billion. Approximately 94% of premiums and services revenue stemmed from government-sponsored programs, underscoring Humana's heavy reliance on Medicare and related federal . Services revenue, primarily from the CenterWell segment encompassing , , and wellness services, represented 3.8% of consolidated totals, with external services at $3.5 billion in 2024. This segment's contributions include intercompany activities that are eliminated in consolidation, but external growth in and benefited from expanded CenterWell operations. Investment and other income supplemented the premiums and services base, though it comprised a minor portion overall. Revenue growth has been robust and sustained, propelled by rising Medicare Advantage enrollment, favorable rate adjustments, and membership gains in government programs. Total revenues reached $117.8 billion in 2024, a 10.7% increase from $106.4 billion in 2023. This followed a 14.5% rise in 2023 from $92.9 billion in 2022, yielding a exceeding 12% over the period. The Insurance segment's expansion, particularly in per-member premiums amid inflation and utilization trends, drove much of this trajectory, though growth moderated in 2024 due to market exits in unprofitable areas and regulatory pressures on star ratings.
Fiscal YearTotal Revenue ($ billions)Year-over-Year Growth (%)
202292.9—
2023106.414.5
2024117.810.7
Longer-term trends indicate consistent double-digit growth since the early 2010s, aligned with Humana's pivot to and Medicare focus, though future projections incorporate risks from utilization spikes and policy changes.

Profitability metrics and challenges

Humana's net profit margin stood at 1.28% for the most recent quarter ending June 30, 2025, reflecting a decline from its three-year average of 2.29%. Return on equity (ROE) was reported at 12.12% as of October 22, 2025. In the second quarter of 2025, the company achieved net income of $545 million, a decrease from $679 million in the same period of 2024, despite revenue growth to $32.4 billion, up 9.6% year-over-year. Adjusted earnings per share (EPS) for the quarter reached $6.27, contributing to raised full-year 2025 guidance of approximately $17 in adjusted EPS.
MetricValue (Q2 2025 or Latest)Year-over-Year Change
Net Profit Margin1.28%Worsened from 3-year avg. of 2.29%
ROE12.12%N/A
$545 millionDown from $679 million
$32.4 billionUp 9.6%
Adjusted EPS$6.27 (Q2)FY 2025 guidance raised to ~$17
Key challenges include escalating medical costs, evidenced by the medical loss ratio (MLR) rising to 89.9% in the second quarter of 2025 from 86.3% the prior year, compressing margins in the segment. Regulatory pressures intensified with Humana's unsuccessful legal challenge to its 2025 star ratings, resulting in an average of 3.5 stars and affecting only 25% of members in four-star or higher plans, down sharply from 94% in 2024; this is projected to lead to membership losses of up to 500,000 by year-end and billions in potential shortfalls. Insurers like Humana have responded by exiting unprofitable markets and reducing plan offerings, contributing to broader contractions amid sustained cost pressures. Despite these headwinds, Humana anticipates adjusted EBIT margins of 2%-3% for 2025, supported by growth projections of 8%-10%.

Stock performance and investor relations

Humana Inc. common stock trades on the under the HUM. As of October 24, 2025, the stock closed at $290.65, reflecting a year-to-date decline amid pressures from enrollment trends and regulatory scrutiny. Over the trailing 12 months ending October 2025, delivered a total return of 13.98%, trailing the 's 16.90%; on a three-year basis, the return was 42.57% versus 78.85% for the ; and over five years, it stood at 31.65% compared to 95.99% for the benchmark. These figures highlight underperformance relative to broader market indices, attributable in part to sector-specific headwinds such as anticipated membership losses of several hundred thousand in plans for 2025 and elevated medical loss ratios.
PeriodHUM ReturnS&P 500 Return
1-Year13.98%16.90%
3-Year42.57%78.85%
5-Year31.65%95.99%
Key events influencing recent stock movements include a 6% surge to $261.71 on October 3, 2025, following announcements of favorable star ratings and reaffirmed guidance, which signaled operational resilience in quality metrics despite broader challenges. Conversely, shares faced downward pressure from second-quarter 2025 earnings that, while reporting $679 million in profit, underscored ongoing headwinds including slower growth and cost containment efforts. Longer-term, Humana's has shown sensitivity to cycles, with post-earnings price moves averaging -1.0% in the immediate session across recent quarters, though positive reactions occurred in seven of the last 12 reports. Humana maintains an portal providing access to financial reports, SEC filings, earnings calls, and presentations, facilitating transparency for shareholders and analysts. The company pursues shareholder returns through consistent quarterly s and share repurchases; for instance, the board declared a $0.885 per share payable on July 25, 2025, marking a steady payout policy. In 2025, Humana executed a buyback program that reduced outstanding shares by 3.8%, reflecting capital allocation toward enhancing per-share value amid healthcare market volatility. Investor communications emphasize updates on dynamics, value-based care initiatives, and guidance revisions, such as the upward adjustment to full-year 2025 adjusted EPS and revenue in July 2025.

Innovations and Achievements

Value-based care models and outcomes

Humana has implemented value-based care (VBC) models primarily through partnerships with providers in its plans, emphasizing shared risk arrangements, capitation payments, and performance incentives tied to quality metrics such as Healthcare Effectiveness Data and Information Set (HEDIS) scores and patient outcomes rather than service volume. These models integrate preventive services, management, and data analytics to align provider incentives with long-term health improvements, covering approximately 70% of Humana's individual members as of 2023. In Humana's VBC arrangements, Medicare Advantage members experienced 11.6% fewer emergency room visits and 7.2% fewer hospital admissions compared to those under traditional models, based on 2023 data from Humana Healthcare . Additionally, VBC patients received more preventive screenings, spent more time with clinicians, and demonstrated higher adherence to evidence-based treatments, contributing to estimated cost savings of $11 billion—or 25.8% of projected expenditures—for Humana in 2023. For specific conditions like , Humana's 2025 research indicated that VBC clinicians delivered higher-quality care, with patients nearly 28% more likely to receive full guideline-directed quadruple therapy, alongside improved medication adherence rates. Independent analyses, such as one from the YIP Institute in 2025, corroborated broader VBC efficacy, noting Humana members had 27% lower hospitalization rates than counterparts. A 2018 report from the Better Medicare Alliance, drawing on Humana data, found VBC-affiliated physicians achieved superior HEDIS outcomes across multiple measures. Humana's Bold Goal initiative, launched in 2014 to improve outcomes by 20% by 2020 through VBC-integrated efforts addressing social determinants like food insecurity, supported these models by enhancing whole-person care coordination. While self-reported, Humana's outcomes align with peer-reviewed findings on VBC's role in effectiveness, as highlighted in a 2025 New England Journal of Medicine publication analyzing similar arrangements. Challenges persist, including provider hurdles and adherence barriers, as noted in Humana's 2022-2025 reports, yet the models have scaled to cover millions of members with sustained reductions in utilization.

Technological and data-driven advancements

Humana has integrated augmented intelligence technologies, emphasizing and , to enhance member health outcomes and operational efficiency. In its Basic Needs Program, launched during the early , predictive models identify members at risk of health decline due to food insecurity, enabling targeted interventions by care teams. The company maintains AI Ethics Operating and Committees, having signed the Equal AI pledge in 2020 to address biases in healthcare utilization patterns observed among certain demographic groups. Partnerships with technology providers have accelerated Humana's data-driven capabilities. A multiyear agreement with Google Cloud, announced in July 2024, focuses on modernizing cloud infrastructure and deploying generative AI models such as Med-PaLM and MedLM to personalize , improve contact center responsiveness, and derive clinical insights while adhering to HIPAA-compliant practices and human oversight for clinical decisions. Similarly, collaboration with Cloud for Healthcare enables advanced predictive models analyzing data from 4.9 million members to forecast acute admissions and readmissions, achieving a 20% improvement in precision through and resampling techniques for proactive care interventions like prescription adjustments. With naviHealth, Humana employs the nH Predict AI tool for post-acute care decisions, reducing readmissions and optimizing care duration. In data exchange, Humana partnered with Providence in October 2025 to implement HL7 FHIR standards and Da Vinci Project APIs, automating member attribution for plans to streamline value-based care coordination, minimize administrative tasks, and support real-time clinical insights across payer-provider boundaries. Additional efforts include conversational AI via to cut pre-service call volumes and Health Cloud for predictive outreach to at-risk members, yielding efficiencies such as fourfold faster care delivery in targeted programs. These initiatives position Humana as a data analytics-focused entity, leveraging vast member datasets to inform management while navigating regulatory scrutiny over AI in coverage determinations.

Community investments and sustainability efforts

Humana's community investments are primarily channeled through the Humana Foundation, which focuses on addressing , such as , , and , in underserved areas. In 2024, the company reported $6.67 million in direct community investments, supporting initiatives aimed at eliminating structural barriers to . These efforts include partnerships with local organizations for and , with employees contributing over 10,000 volunteer hours in the same year. The Foundation's grants, which totaled nearly $25 million in 2023, target programs improving access to care and community vitality, often in collaboration with Humana's operational footprint in markets. In 2025, the Humana Foundation expanded its national grants to over $12 million, emphasizing interventions against , chronic illness, and cultural factors affecting senior health outcomes. This builds on the company's Bold Goal initiative, launched in 2014 to improve metrics by 20% by 2020 and sustain progress thereafter, measured through indicators like self-reported healthy days. While self-evaluations in annual impact reports claim advancements in , independent verification of long-term outcomes remains limited, with progress tied to localized pilots rather than broad causal impacts. On sustainability, Humana pursues environmental goals aligned with science-based targets, including a validated commitment by the to reduce emissions. In , the company achieved a 14.5% reduction in Scope 1 and 2 compared to baseline levels, equivalent to avoiding 242,315 metric tons of CO2. These efforts encompass operational efficiencies like in facilities and optimizations, as outlined in Humana's Environmental Policy updated in March . The Impact Report frames these as integral to broader ESG strategies, though quantifiable links to member health or financial returns are primarily internal assessments without third-party audits cited.

Campaigns against drug price collusion

In August 2018, Humana filed an antitrust lawsuit in the U.S. District Court for the Eastern District of Pennsylvania against more than two dozen generic drug manufacturers, including Teva Pharmaceutical Industries, Mylan, and Apotex, alleging a conspiracy to fix prices and allocate market shares for widely used generic medications. The complaint asserted that defendants engaged in bid-rigging, customer allocation, and price-setting agreements, artificially inflating costs for insurers like Humana, which paid overcharges on drugs such as those for hypertension and cancer treatment. These actions, Humana claimed, violated the Sherman Antitrust Act by suppressing competition, with the suit seeking treble damages for losses incurred since at least 2010. The litigation expanded in 2019 with a 610-page amended complaint naming 37 defendants and detailing a "far-reaching " affecting dozens of generics, including mesylate, where prices reportedly surged by up to 1,000% due to coordinated reductions in supply and production. Humana referenced ongoing federal investigations and congressional reports on generic anomalies as supporting evidence of industry-wide , positioning its claims within multidistrict litigation (MDL No. 2724) consolidating similar insurer and direct-purchaser suits. No major settlements specific to Humana's generic claims have been publicly resolved as of 2025, though parallel criminal probes have led to guilty pleas from some executives in unrelated but similar cases. Humana has pursued related claims against branded drug makers for practices enabling effective price collusion, such as pay-for-delay settlements delaying generic entry. In November 2023, it sued in the U.S. District Court for the District of , accusing the company of orchestrating anticompetitive schemes involving Zetia and Vytorin through invalid patents, sham litigation, and reverse payments to generic challengers, which maintained monopoly pricing. Most of these allegations survived a motion to dismiss in September 2025, allowing the case to proceed on Sherman Act violations. Similarly, in a 2025 First Circuit ruling, Humana's Racketeer Influenced and Corrupt Organizations Act claims against and Associates of Cape Cod for fraudulent schemes inflating drug prices were upheld for further review. These efforts underscore Humana's strategy to challenge structural barriers to competition, though critics from pharmaceutical trade groups argue such suits overlook legitimate protections.

Compliance with Medicare and federal regulations

Humana operates extensive (Part C) and (Part D) plans, subjecting it to stringent federal oversight by the (CMS) and the Department of Health and Human Services Office of Inspector General (OIG). Compliance requires accurate risk adjustment data submission, proper beneficiary notifications, and adherence to bidding and payment rules under 42 CFR Parts 422 and 423. In multiple OIG audits, Humana's submission of codes for CMS risk adjustment payments has been found non-compliant with federal requirements for . A September 2024 OIG of Humana Health Plan Inc. (contract H2649) examined codes for high-risk conditions in 2018-2019 enrollee-years, determining that 75% of sampled diagnoses lacked supporting , leading to unsupported payments of approximately $4.1 million from a projected $82.7 million over the period. An April 2023 of HumanaChoice (contract H6609) for 2015-2016 similarly identified unsupported risk adjustment payments totaling $12.7 million in the sample, extrapolated to $197 million overall due to inadequate chart reviews. CMS has imposed civil monetary penalties (CMPs) on Humana for Part D violations. On January 17, 2025, CMS assessed a CMP for failures in 2021 related to coordination of benefits and low-income subsidy (LIS) determinations, stemming from a 2023 financial audit that identified discrepancies in drug cost reporting and beneficiary eligibility processing. A November 2022 CMP addressed inaccuracies in gross covered drug costs and True Out-of-Pocket (TrOOP) accumulators, violating Part D payment integrity rules. Humana has resolved federal False Claims Act allegations through settlements without admitting liability. In August 2024, it agreed to pay $90 million to settle claims that it submitted inflated bids for Part D contracts from 2014-2018, allegedly overcharging Medicare by misclassifying drugs to maximize payments; a related September 2025 required an additional $32 million in whistleblower attorney fees. Earlier, in an undisclosed settlement, Humana paid $411,000 for false statements supporting electronic health record meaningful use incentives under Medicare. In regulatory challenges, Humana successfully contested CMS's Risk Adjustment Data Validation (RADV) methodology. A September 2025 federal court ruling vacated the 2023 CMS final rule allowing extrapolation of overpayment recoveries from sampled enrollees to entire contracts for payment years 2018-2024, limiting CMS to recovering only audited amounts and halting broader plans. However, Humana's October 2025 challenge to its 2025 star ratings was dismissed, upholding CMS's evaluation of plan performance metrics affecting reimbursements.

Recent litigation outcomes

In October 2025, a federal judge in dismissed Humana's second lawsuit seeking recalculation of its 2025 star ratings, ruling that the (CMS) did not exceed its statutory authority or act arbitrarily in applying its quality bonus methodology. The suit, filed in July 2025 after an initial challenge failed, alleged flaws in CMS's auditing and appeals processes that penalized Humana's ratings, potentially reducing reimbursements by hundreds of millions; the dismissal with prejudice ended Humana's legal recourse on the matter. In September 2025, a U.S. District Court ordered Humana to pay $32.2 million in attorneys' fees, costs, and interest to relators' counsel in a False Claims Act case resolved via settlement, stemming from allegations of systematic upcoding in risk adjustment practices that inflated payments from the . The underlying agreement required Humana to remit approximately $90 million to the U.S. Department of Justice to settle claims of improper hierarchical condition category coding from 2011 to 2016, marking one of the larger recoveries in Medicare overpayment whistleblower actions. These outcomes reflect ongoing scrutiny of Humana's compliance with federal reimbursement rules, though the company maintained in public statements that its practices align with CMS guidelines and denied wrongdoing in the False Claims resolution. No major trial verdicts against Humana were reported in 2023–2025 beyond these dispositions, with other actions such as class claims over utilization denials remaining pending.

Controversies

Allegations of overbilling and improper payments

In 2015, a federal audit by the Department of Health and Human Services' Office of Inspector General determined that Humana's plan in improperly collected approximately $197.8 million by overstating the severity of beneficiaries' medical conditions through inaccurate risk adjustment data submissions, leading to inflated payments from the (CMS). The audit examined diagnoses submitted for over 200,000 enrollees and found that Humana failed to remove unsupported diagnoses, resulting in overpayments that CMS has historically struggled to recover fully across Medicare Advantage plans. Separate audits conducted between 2011 and 2018 revealed overpayments to Humana exceeding $1,000 per audited contract in 10 of 11 cases, primarily due to unsubstantiated codes used for adjustment, a common mechanism in where payments are tied to enrollee health scores. These findings contributed to broader CMS estimates of improper payments in the program totaling billions annually, though Humana has contested the methodologies and recovery demands in administrative appeals. In August 2024, Humana agreed to pay $90 million to resolve a False Claims Act whistleblower lawsuit filed by a former company , who alleged that from 2014 onward, Humana submitted fraudulent bids to CMS for prescription drug plans by intentionally overstating projected drug costs to secure higher government reimbursements, potentially overcharging by tens of millions annually. The settlement, the first of its kind involving Part D bid manipulation, did not include an admission of liability by Humana, but in September 2025, a federal court ordered the company to pay an additional $32.2 million in attorneys' fees to the whistleblower's legal team, affirming the relator's share under the False Claims Act. Additionally, in a settlement, Humana paid $1.8 million to resolve allegations that it violated the Civil Monetary Penalties Law by submitting prescription drug event claims under that improperly included reimbursements, resulting in overpayments for transactions from 2009 to 2016. These cases highlight recurring scrutiny of Humana's billing practices in government-funded programs, where risk adjustment and bid accuracy directly influence reimbursement levels, though the company maintains compliance with CMS guidelines and attributes discrepancies to complex processes.

Utilization management and denial practices

Humana employs techniques, including requirements and medical necessity reviews, primarily in its plans to assess the appropriateness of services such as post-acute care. These processes involve evaluating provider requests against clinical guidelines and predictive tools to control costs and prevent overuse, with Humana processing approximately 2.9 prior authorization requests per enrollee annually, higher than the Medicare Advantage average of 1.7. In 2023, Humana denied 3.5% of requests across its plans, below the industry range of up to 13.6% for some competitors, though denials were markedly higher for specific services like post-acute care at 24.6%, exceeding overall rates by a factor of 16. A U.S. report highlighted that Humana's denial rates for long-term hospital services rose 54% between 2020 and 2022 following internal training on its nH Predict , which forecasts length-of-stay in skilled facilities and influences coverage decisions. Critics, including patient advocates and a December 2023 class-action , allege that Humana's reliance on nH Predict and similar AI tools overrides physicians' judgments, leading to premature denials of rehabilitative care for seriously ill beneficiaries and potentially prioritizing profit over medical needs. The suit, which advanced to class certification in August 2025, claims the algorithm's probabilistic predictions result in systematic underestimation of required care durations. Approximately one-third of enrollees, including those in Humana plans, face at least one denial annually, with broader surveys indicating that 61% of physicians worry AI exacerbates avoidable delays and treatment abandonment. Humana maintains that its practices align with Medicare guidelines and that denied claims often succeed on appeal, with 68.4% of Humana appeals overturned in favor of enrollees. In response to scrutiny, the company announced in July 2025 plans to eliminate one-third of outpatient prior authorizations by 2026 and achieve 95% same-day decisions, aiming to reduce administrative burdens while preserving safeguards against unnecessary utilization. These efforts follow data showing overall denial rates declined slightly to 6.4% in 2023, though post-acute care remains a flashpoint for disputes.

Star ratings disputes and market impacts

In 2024, Humana challenged the (CMS) star ratings for its plans, particularly citing a decline to 3.5 stars for its largest contract due to failures in three test phone calls assessing callback responsiveness. Humana contended that CMS's methodology, including the weight given to these secret shopper audits, was arbitrary and unlawfully penalized the insurer without , as the ratings directly influence quality bonus payments tied to plan performance metrics like member experience and care coordination. The initial lawsuit, filed in the U.S. District Court for the Northern District of Texas, was dismissed in 2024 on procedural grounds by Judge Reed O'Connor, prompting Humana to refile in July 2024 with refined arguments that CMS exceeded its statutory authority under the Social Security Act. On October 14, 2025, the court dismissed the refiled case with prejudice, ruling that CMS's actions were lawful and within its regulatory discretion to enforce star rating criteria, including call center audits that Humana had appealed unsuccessfully through administrative channels. This outcome aligned with similar unsuccessful challenges by other Medicare Advantage insurers, underscoring CMS's broad interpretive authority over rating appeals. The star ratings disputes have imposed significant market pressures on Humana, which derives over 80% of its revenue from enrollment exceeding 5 million members. A 3.5-star average for key plans forfeits substantial quality bonuses—potentially billions in federal reimbursements annually—as payments scale with ratings above 4 stars, leading Humana to project enrollment declines and redirect marketing toward its fewer higher-rated plans. For 2026, only about 20% of Humana's members are projected to be in 4-plus star plans, down from 25% in 2025 and a peak near 94% in prior years, exacerbating competitive disadvantages against rivals like UnitedHealth maintaining stronger averages. Financially, the upheld lower ratings contributed to a sharp post-ruling dip in Humana's stock price on October 15, 2025, reflecting investor concerns over reduced bonuses and potential membership erosion amid CMS's emphasis on consumer-facing metrics. Humana has responded by enhancing call center protocols and prioritizing growth in compliant, higher-rated offerings, though analysts note persistent risks from rating volatility tied to opaque CMS audit practices.

Defenses of operational efficiency and member benefits

Humana has defended its measures, including and value-based care models, as essential for delivering enhanced member benefits in plans while controlling costs. These strategies, such as prior authorizations and care coordination, are argued to prevent unnecessary procedures, thereby reducing overall healthcare expenditures and enabling reinvestment into supplemental benefits like dental, vision, and fitness programs that exceed those in traditional Medicare. In value-based care arrangements, Humana reports that Medicare Advantage members treated by participating clinicians experienced 11.6% fewer emergency room visits and 7.2% fewer hospital admissions compared to those in fee-for-service models, attributing these outcomes to proactive management that prioritizes preventive and coordinated care over reactive interventions. Such efficiencies generated 25.8% lower medical costs in 2023 relative to Original Medicare benchmarks, with savings directed toward expanded member benefits including over-the-counter allowances and transportation services. Utilization management programs are positioned by Humana as safeguards that ensure treatments align with evidence-based guidelines, fostering cost-effectiveness without compromising quality; for instance, these processes guide members toward appropriate options, reducing waste and supporting improvements. Company executives have highlighted ongoing investments in and clinical protocols as drivers of margin recovery, allowing sustained delivery of high-value plans amid rising utilization pressures. Historically, these efforts correlated with strong CMS Star Ratings, where 94% of Humana members were in plans rated 4 stars or higher for 2024, reflecting perceived quality in member services and outcomes; proponents argue that efficiency underpins such ratings by enabling robust benefit packages and member support programs. Despite recent rating declines, Humana maintains that operational refinements will restore top-quartile performance by 2027, continuing to prioritize member-centric efficiencies.

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