Geographical expansion isn’t the only tool big insurers use to increase Medicare Advantage enrollment, Ellis said.

Cigna and Humana have complained that competitors are underestimating Medicare Advantage plans and cutting market share this year, Ellis said. Pricing is difficult to track because it varies by county, making it difficult to determine which insurers might be strategically setting premiums at low rates, he said.

“It’s not a sustainable strategy, and it’s more of a concern to us than the overall slowdown,” Ellis said. “In terms of these big insurers sticking to service, benefits and maintaining what they’ve been doing for some time, I think margin pricing will benefit them.”

Centene received the most Medicare Advantage beneficiaries, with enrollments up 12.9% to 1.2 million.

This year, Centene expanded to 327 new counties and three new states. The insurer is also integrating its health insurance brands under WellCare, which Centene acquired in 2019 for $17 billion. The company holds nearly 4% of the Medicare Advantage market.

UnitedHealthcare also continued to dominate the market, with membership up 5.2% sequentially to 7.9 million.

The UnitedHealth Group subsidiary expanded to 276 new counties this year and now controls nearly 28 percent of the market. Most new policyholders switch from local operators or Humana. UnitedHealthcare will cover as many as 800,000 new enrollees this year, about 75 percent from individual and group Medicare Advantage plans and the rest from Medicare-Medicaid Special Needs plans.

Aetna’s membership grew faster than the market as a whole, increasing 4% to 3 million. The CVS Health subsidiary expanded its Medicare Advantage footprint to 83 new counties and began offering Medicare-Medicaid special needs programs in Arkansas, Colorado, Delaware and Indiana. Aetna now covers nearly 11% of Medicare Advantage participants.

This year, Aetna launched its first CVS-branded wellness program, and CVS Pharmacy’s retail footprint of nearly 10,000 stores could help drive sign-ups, said Ari Gottlieb, principal at A2 Strategy Group. “It shows that putting agents and brokers in stores frequented by older people has the potential to really drive enrollment,” he said.

Anthem employs a similar strategy cooperate with Kroger’s arrangement gives policyholders access to the grocery chain’s 2,300 pharmacies and 200 clinics in Atlanta, Louisville, Kentucky, Cincinnati and southern Virginia. Still, Anthem underperformed the Medicare Advantage market during this year’s enrollment.

“It’s a very competitive market. It’s still a very competitive market,” Anthem Chief Executive Gail Boudreaux told investors last quarter.

Cigna is the only major commercial insurer to have fewer Medicare Advantage policyholders at the end of the enrollment period than the previous year.

Enrollment growth at Humana has slowed after conservatively pricing 2022 margins, according to a Bank of America report. Humana and UnitedHealthcare tend to lose customers over time, the report said.

Unlike Humana, Cigna and Alignment Healthcare, which have cited aggressive pricing by rivals to reduce market share, UnitedHealthcare doesn’t believe new entrants will make the market more competitive.

“The MA market has been very competitive over the years, and I don’t think the level of competitiveness will increase significantly in 2022,” Tim Noel, chief executive of UnitedHealthcare’s Medicare and Retirement division, told investors in the fourth quarter. “The trend towards more entrants [and] Better perks are indeed over the years. We think this trend is very good for seniors and very good for the overall growth of the Medicare Advantage industry. “

Insurtechs Devoted Health and Clover Health both grew membership faster than the overall market. Devoted Health credits providers with recommendations, while Clover Health credits its extensive network with attracting customers. Both companies deny underpricing their products and say big insurers have cut their market share.

In addition to start-up insurers, the Blue Cross and Blue Shield programs have been increasing their investments in Medicare Advantage over the past five years, Gottlieb said. For example, Blue Cross and Blue Shield in North Carolina grew membership by 14.4 percent to nearly 82,000 during open enrollment.

Blue Cross and Blue Shield carriers haven’t traditionally focused on Medicare Advantage, but they’ve made inroads as the market continues to grow faster than other businesses, Gottlieb said. As policyholders age, these companies have the potential to convert their large commercial, personal and Medicaid customer bases into Medicare Advantage members. This gives them an advantage over start-up and national insurers that may lack local supplier and broker relationships, he said.

“How do they use business books to convert people into health insurance as they get older?” Gottlieb said. “To the extent they can create seamless products, it’s a huge opportunity.”