Oscar Health, Inc. (Oscar) operates as a health technology company.
The company builds around a full stack technology platform and a relentless focus on member experience. The company offers health plans through the Patient Protection and Affordable Care Act (ACA) serving individuals, families, and employees. The company has been challenging the status quo in the healthcare system and is dedicated to making a healthier life accessible and affordable for all. The company’s technology drives supe...
Oscar Health, Inc. (Oscar) operates as a health technology company.
The company builds around a full stack technology platform and a relentless focus on member experience. The company offers health plans through the Patient Protection and Affordable Care Act (ACA) serving individuals, families, and employees. The company has been challenging the status quo in the healthcare system and is dedicated to making a healthier life accessible and affordable for all. The company’s technology drives superior experiences, deep engagement, and high-value clinical care, earning it the trust of approximately 1.68 million effectuated members, as of December 31, 2024.
In addition to supporting its insurance business, the company’s differentiated technology platform also powers both providers and payors through +Oscar. The company offers Campaign Builder, an engagement and recommendation platform that leverages the wisdom from 12+ years of building the Oscar member experience. The platform delivers continuous care management by informing population identification and delivering personalized interactions with real time reporting and analytics to measure key outcomes and insights.
Offerings
Oscar’s innovative technology-enabled model - made up of Oscar’s insurance business and +Oscar - is uniquely positioned to meet the rising expectations of individuals, families, and employees, as well as +Oscar clients. Oscar's business is built upon the company’s focus on member experience and the company’s cloud-native technology platform.
Oscar's Insurance Business
Oscar's health plans are offered in the individual market. The individual market primarily consists of policies purchased by individuals and families through health insurance marketplaces, established by the ACA and operated by the federal government, as well as other marketplaces operated by individual states (collectively, Health Insurance Marketplaces). Individuals and families may also purchase policies in the individual market off-exchange. Employees whose employers have chosen to offer an Individual Coverage Health Reimbursement Arrangement (ICHRA) are also able to purchase Oscar’s health plans. Most ICHRA plans are purchased by employees off-exchange, although they may also be purchased through the Health Insurance Marketplace.
The company offers health plans in the individual market under the five metal plan categories defined by the ACA: Catastrophic, Bronze, Silver, Gold, and Platinum. These plans differ based on the size of the monthly premium and the level of sharing of medical costs between Oscar and the company’s members. Oscar works to bring new and innovative insurance products to market, built to meet the healthcare needs of consumers from various communities. Oscar does this with an eye towards promoting health outcomes, accessibility, affordability, and closing critical gaps in benefits for consumers. The company’s products help remove financial barriers to high-value services, with a focus on leveraging affordable care, clinical strategies, and its innovative business model, which collectively, empower and incentivize its members to have better control of their health. Some of the company’s products incorporate benefits and programs of particular value to members with complex conditions, such as diabetes and asthma.
The company’s premium rates, along with specific rate changes, are required to be approved by applicable state and federal regulatory agencies in accordance with the ACA. Additionally, various federal and state laws have minimum Medical Loss Ratio (MLR) requirements.
+Oscar Platform
Oscar’s success is built upon the company’s superior member engagement and robust technology platform. Through the +Oscar platform, the company deploys its technology to power others throughout the healthcare system. Campaign Builder, the company’s engagement and recommendation platform for providers and payors, leverages predictive analytics to identify high value opportunities for engagement and to deliver personalized interactions with real time reporting and analytics to measure key outcomes and insights. +Oscar serves nearly 500,000 client lives on its Campaign Builder platform, in addition to the approximately 1.68 million members enrolled in Oscar health insurance, in each case as of December 31, 2024.
Provider Contracts and Network
The company’s health plans include access to a network of high-quality physicians and hospitals, as well as a Care Team that supports members from finding a doctor to navigating costs. As portions of the healthcare system increasingly shift towards offering more selective networks, the insurers that will thrive are those that consistently deliver a high-quality experience by engaging their members and routing care to in-network facilities and physicians that offer quality care at affordable rates. Oscar has exclusive provider organization (EPO) plans in most of the company’s markets, and also offers health maintenance organization (HMO) plans in select markets. The company works with technology-forward, high brand-recognition health systems, including some of the largest health systems in the U.S.
While it generally has a standard set of terms that the company proposes for its provider contracting relationships, each health market in which it operates is unique, and therefore its negotiated contract terms are specific to each market and health provider.
Membership
Markets
Oscar's member-first philosophy and innovative approach to care earned the company the trust of approximately 1.68 million effectuated members as of December 31, 2024. The company offers coverage for individuals and families in 18 states. The company regularly evaluates its markets for strategic fit and enter or exit markets accordingly. The company exited the Medicare Advantage market before the 2024 plan year and stopped offering small group products in all markets as of December 15, 2024.
Concentration
The company generates the vast majority of its total revenue from health insurance policy premiums. Premiums are collected directly from the Centers for Medicare & Medicaid Services (CMS) as part of the advanced premium tax credits (APTC) program, as well as from its members.
Seasonality
The company’s business is generally affected by the seasonal patterns of its member enrollment, medical expenses, and health plan mix shift and policy design. Special Enrollment Periods (SEP) or other market dynamics that drive enrollment and/or mix changes throughout the year may impact the per member levels of premiums, claims, and/or risk adjustment transfers.
SEP refers to a period outside the Open Enrollment Period or Annual Election Period when an eligible person can enroll in a health plan or make changes to an existing health plan. A person is generally eligible to participate in a SEP if certain qualifying life events occur, such as losing certain health coverage, moving, getting married, having a baby, or adopting a child or resulting from regulatory requirements.
Members
The company’s membership is measured as of a particular point in time. Membership may vary throughout the year due to disenrollments, any SEP, and other market dynamics that are in effect, such as Medicaid redeterminations, other legislative or regulatory actions, or other factors that enable the overall market to grow or decline throughout the year.
Claims Incurred
The company’s medical expenses are impacted by seasonal effects of medical costs, such as the utilization of deductibles and out-of-pocket maximums over the course of the policy year, which shifts more costs to it in the second half of the year as it pays a higher proportion of covered claims costs, and the number of days and holidays in a given period. The company’s medical and pharmacy costs can also exhibit seasonality depending on selection effects or changes in the risk profile of its membership and the proportion of its membership that is new in the calendar year.
Differentiated Technology Platform
Oscar’s technology stack is purpose-built to empower the modern consumer throughout different stages of life. The company has built its own cloud-native single-threaded technology platform, meaning it spans all critical healthcare insurance and technology domains, including member and provider data, utilization management, claims management, billing, and benefits. Owning the company’s platform from end to end offers it greater control over the member experience, engagement, and affordability, and enables it to provide a superior experience for its members and providers.
The company’s technology platform provides members with a simple and intuitive consumer experience that enables them to take control of their healthcare decisions. The Oscar member experience begins with trust and engagement, which the company earns by providing its members with features to help them navigate the many disconnected elements of the healthcare ecosystem.
The company’s ability to deliver a high-value product, in turn, engenders more trust, engagement, and ability on its part to provide personalized, data-driven insights. The company refers to this virtuous cycle as its member engagement engine.
By leveraging Campaign Builder, the company’s engagement and automation engine, it is able to rapidly create and iterate upon omnichannel member outreach programs to drive adherence to important clinical pathways. Owning the technologies that power the company’s business from end to end lets it pioneer new ways of addressing frictions in the healthcare system and is the foundation for Oscar’s mission to make a healthier life accessible and affordable for all. This platform provides the foundation for the company’s personalized data insight and analysis, as well as its structure savings. As a result, engagement with its technology platform and customer satisfaction remains high, relative to industry average. During the fourth quarter of 2024, the company’s net promoter score reached 66, which is meaningfully higher than the industry average.
The company’s platform is an increasingly powerful force driving the performance of Oscar's insurance business – fueling growth, engagement, and operational efficiencies. Artificial Intelligence and machine learning technologies (AI Technologies) have the potential to further power what it can do. The company has use cases for AI Technologies in the pipeline across all levels of its technology stack, including: automation to drive efficiencies in its administrative functions, including virtual care and claims processing; member personalization, to improve the quality of touchpoints members have with the healthcare ecosystem; and medical record extraction, to better understand its members.
Strategy
The company builds its strategy around several core trends in healthcare including consumerization, digitization, and the shift towards personalization. The company is a scaled health insurer with approximately 1.68 million effectuated members as of December 31, 2024. The company offers an exceptional member experience, high member engagement, and its own technology stack that it has built from end to end.
The company continues to believe that ICHRA will disrupt traditional employer group coverage and expand individual insurance beyond the traditional ACA market. The company is partnering with a variety of ICHRA platforms to transition small, mid- and large-sized employers to the individual market where their employees can choose an Oscar product that meets their individual needs.
The company’s strategic priorities include running a great company with market-leading, sustainable, scalable operations; continually investing in its superior member experience; harnessing its technology to power others; and developing innovative market offerings to expand the individual market.
Sales and Marketing
The company’s marketing and sales initiatives focus on member growth through three primary avenues: acquiring members through brokers, acquiring members directly through Health Insurance Marketplaces, and acquiring members directly through its digital platform. As a part of its Individual Coverage Health Reimbursement Arrangement (ICHRA) initiatives, the company also partners with ICHRA platform companies to enroll employees in Oscar plans through their platforms.
The vast majority of the company’s membership is acquired through the broker channel, and brokers typically use an Enhanced Direct Enrollment (EDE) platform to enroll the members in plans offered on the Health Insurance Marketplace. The company’s digital engagement platform, a key element of its retention strategy, is used by brokers and consumers.
Enterprise marketing and sales strategies also include account-based marketing, business development initiatives, member communications that are focused on member acquisition, and member engagement. The company also uses the data generated in member support interactions to constantly refine and improve its marketing campaigns.
Intellectual Property
As of December 31, 2024, the company exclusively owned three registered trademarks in the United States for its name (Oscar, Oscar Health, and Oscar Care). In addition, the company had registered domain names for websites that it uses or may use in its business.
Government Regulations
Most of the company’s subsidiaries are subject to requirements based on the Risk-Based Capital For Health Organizations Model Act, with a few subsidiaries subject to state-specific RBC requirements that are not based on, but function similarly to, the Model Act. These RBC requirements are intended to assess the capital adequacy of life and health insurers and HMOs, taking into account the risk characteristics of a company’s investments and products. In general, under these laws, an insurance company or HMO must submit a report of its RBC level to the insurance regulator of its state of domicile.
The company maintains an internal HIPAA compliance program, which is designed to comply with the Health Information Technology for Economic and Clinical Health Act of 2009 (together, HIPAA) privacy and security regulations, adapt to new requirements if finalized, and have dedicated resources to monitor compliance with this program.
The use and disclosure of certain data that the company collects or processes about or from individuals are also regulated in some instances by other federal laws, including the Gramm-Leach-Bliley Act (GLBA), and state statutes implementing GLBA, in connection with insurance transactions in the states where it operates.
Because the company receives payments from federal governmental agencies, it may be subject to various laws commonly referred to as fraud, waste, and abuse laws, including the federal Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), and the False Claims Act (FCA). These laws permit the Department of Justice (DOJ), the HHS Office of Inspector General (HHS-OIG), Centers for Medicare and Medicaid Services (CMS), and other enforcement authorities to institute a claim, action, investigation, or other proceeding against the company for violations and, depending on the facts and circumstances, to seek treble damages, criminal, civil, or administrative fines, penalties, and assessments.
History
Oscar Health, Inc. was founded in 2012. The company was incorporated in 2012.