NUA Strategy for Health Insurance & Managed Care Employees (UnitedHealth Group, Elevance Health, Cigna, HCA Healthcare, Humana)

Health insurance and managed care employees are among the most consistently overlooked NUA candidates in the workforce. UnitedHealth Group (UNH) stock appreciated from roughly $25/share at the 2009 trough to $402 in August 2026 — a 16:1 ratio for the earliest post-crisis contributors, and 7:1 to 8:1 for 2012 contributors. Elevance Health (formerly Anthem, formerly WellPoint) moved from approximately $65/share in 2012 to $399, a 6:1 ratio. HCA Healthcare IPO'd at $30/share in March 2011 and now trades above $418, delivering a 14:1 ratio to early participants. Cigna (CI) offers 6:1 to 7:1 ratios for 2012 contributors; Humana (HUM) offers 5:1 to 6:1. At those ratios and in the 32–37% federal bracket, the NUA election saves $100,000–$250,000 in lifetime federal tax per position. The sector-wide complication: most company headquarters are in states that tax long-term capital gains as ordinary income — Minnesota (UNH), Indiana (ELV), Connecticut (CI), and Kentucky (HUM). The federal savings remain very large even without a state advantage. HCA's Nashville, Tennessee base is the exception: TN has no state income tax, and HCA employees capture the full federal NUA benefit without erosion.

Why managed care positions produce strong NUA ratios

Three factors combine to create favorable NUA conditions across this sector:

• Post-financial-crisis trough contributions. Major managed care stocks bottomed during the 2008–2009 recession alongside the broader market. Long-tenure employees who contributed through their 401(k) employer stock funds during the 2009–2012 period accumulated shares at prices that now look like bargains: UNH at $25–$52/share, ELV at $57–$65/share, CI at $40–$55/share, HUM at $52–$70/share. At today's prices, those contribution eras produce 6:1 to 16:1 ratios.
• Industry-wide premium growth. Managed care stocks have benefited from two decades of rising healthcare premium revenue, Medicare Advantage expansion, and growing enrollment. Unlike cyclical industries (energy, automotive, steel), healthcare insurance provides relatively stable and growing cash flows — which means stock prices have risen steadily, with some volatility.
• Long employee tenure in corporate and clinical operations roles. These companies employ large populations of long-tenure workers: claims processors, utilization management nurses, corporate IT, actuaries, and population health analysts. Many have 20–35 year careers at a single employer, accumulating employer stock over multiple market cycles. The result is basis from multiple contribution eras with widely varying prices — making lot selection for partial NUA particularly valuable.

UnitedHealth Group (UNH): the largest managed care employer

UnitedHealth Group employs approximately 400,000 people across its two main segments: UnitedHealthcare (health insurance plans) and Optum (pharmacy benefit management, health analytics, and care delivery). It is the largest employer in this sector and one of the most common 401(k) employer stock NUA situations a specialist will encounter.

Recordkeeper: Fidelity Management Trust Company serves as trustee, with Fidelity Workplace Services LLC as recordkeeper. Participants access accounts through Fidelity NetBenefits.¹

Employer stock fund: The plan includes a UnitedHealth Group Stock Fund holding UNH common stock. Participants can direct contributions or transfers into this fund. Employer match dollars are invested in the participant's chosen fund allocation, not automatically in UNH stock — but employees who chose to overweight the employer stock fund over time, or who participated in PacifiCare's plan before UNH acquired PacifiCare in 2005, may hold significant UNH positions.

Appreciation by contribution era:

Minnesota state tax: UNH is headquartered in Minnetonka, Minnesota, and most corporate employees live in the Minneapolis–Saint Paul metro area. Minnesota's top income tax rate is 9.85% on income above $183,340 (MFJ, 2026), and Minnesota taxes long-term capital gains as ordinary income. This means UNH employees capture a federal-only NUA benefit — no state LTCG rate advantage. At 37% federal bracket, the federal NUA savings are still very large: approximately 13.2 cents per dollar of NUA appreciation (37% OI rate minus 23.8% LTCG+NIIT rate). See Worked Example 1 for the full calculation.

Elevance Health / Anthem (ELV): three names, one cost basis chain

Elevance Health is the nation's second-largest health insurance company, serving approximately 46 million members under the Blue Cross Blue Shield brand in 14 states. Long-tenure employees face one specific complication before modeling their NUA: the company has operated under three different legal names since 2000.

Name change timeline:

• WellPoint Health Networks (founded 1992) — merged with Anthem Inc. in 2004
• WellPoint Inc. (2004–November 2014) — the combined entity after Anthem and WellPoint merged; traded as WLP
• Anthem Inc. (November 2014–June 2022) — name change only, same legal entity, ticker changed to ANTM then ELV
• Elevance Health, Inc. (June 2022–present) — current name, ticker ELV

Cost basis impact: All three name changes were internal corporate rebranding events — there were no stock mergers, share exchanges, or taxable restructurings involved. An employee who held WellPoint stock (WLP) in 2005 now holds Elevance Health stock (ELV) with the same continuous basis. There is no basis reset, no exchange ratio, and no tax event from the name changes themselves. Your recordkeeper's cost basis records for ELV trace continuously back to whatever price you paid when the shares were originally contributed, regardless of what the company was called at the time.

Recordkeeper: Fidelity Management Trust Company (trustee) and Fidelity Workplace Services LLC (recordkeeper). The plan includes an Elevance Health stock fund; as of year-end 2022, the plan held approximately 1.29 million shares of ELV common stock.²

Appreciation by contribution era:

Indiana state tax: Elevance Health is headquartered in Indianapolis. Indiana has a flat 3.15% state income tax rate and taxes long-term capital gains as ordinary income. Like UNH in Minnesota, ELV employees receive a federal-only NUA advantage. The federal savings still dominate: for a $500,000 NUA position in the 37% federal bracket, the federal savings exceed $60,000 regardless of Indiana's treatment.

Cigna (CI): Express Scripts merger context

Cigna Corporation is a global health services company employing approximately 70,000 people. Its NUA profile differs from UNH and ELV in one important way: the March 2018 acquisition of Express Scripts, the nation's largest pharmacy benefit manager.

Long-tenure Cigna employees (pre-2018 contributions): Employees who contributed CI employer stock to their 401(k) before the Express Scripts merger have basis from contribution eras when CI traded at $40–$55/share (2012) or $130–$150/share (2015). At the current CI price near $278, those 2012 contributions produce a 6:1 to 7:1 ratio — a solid NUA opportunity.

Former Express Scripts employees (post-2018 Cigna shares): When Cigna acquired Express Scripts in March 2018, the deal closed at approximately $96.03 per ESI share in a combination of cash and Cigna stock. Express Scripts employees who held ESI in their 401(k) received CI shares at a conversion price of roughly $163/share. At CI's current price of $278, those converted shares show approximately 1.7:1 appreciation — well below the threshold where NUA typically justifies the complexity. Former Express Scripts employees should request their exact per-share cost basis from Cigna's recordkeeper before assuming NUA applies.

Recordkeeper: Cigna uses Fidelity as its 401(k) recordkeeper. Cost basis for employer stock contributions — including pre-2018 CI shares and post-2018 converted ESI shares — is tracked in Fidelity NetBenefits.

Connecticut state tax: Cigna is headquartered in Bloomfield, Connecticut. Connecticut's top marginal income tax rate is 6.99%, and the state taxes long-term capital gains as ordinary income. Cigna employees receive a federal-only NUA benefit, but the federal savings for a pre-2018 contributor in the 35–37% bracket remain substantial.

HCA Healthcare (HCA): the hospital operator with a Tennessee tax advantage

HCA Healthcare is the largest for-profit hospital operator in the United States, operating more than 180 hospitals and 2,000 ambulatory care sites across 20 states and the UK. Its NUA story includes a unique valuation event that creates strong appreciation ratios — and a headquarters state that delivers the full NUA benefit.

Going-private and re-IPO: HCA was taken private in November 2006 via a leveraged buyout by KKR, Bain Capital, Merrill Lynch, and the Frick family for approximately $21 per share. After recapitalizing during the financial crisis, HCA returned to public markets in March 2011 with an IPO priced at $30 per share. Employee 401(k) plans holding HCA stock before the 2006 going-private transaction received cash at the tender price. The employer stock now held in HCA 401(k) plans consists of shares accumulated from the March 2011 re-IPO onward. Employees who joined HCA before 2006 do not carry pre-IPO basis into the current plan; their basis reflects contributions made after the 2011 re-listing.

Appreciation since the re-IPO:

Tennessee tax advantage: HCA Healthcare is headquartered in Nashville. Tennessee has no state income tax on wages, investment income, or capital gains. HCA employees — whether nurses, corporate staff, or hospital administrators — capture the complete federal NUA advantage without state tax erosion. For a large position, this can mean an additional $30,000–$70,000 in savings compared to the same employee in Minnesota or Connecticut.

Recordkeeper: HCA's 401(k) plan includes HCA common stock as a participant investment option held in the HCA Master Retirement Trust. Contact HCA's benefits hotline or your plan portal to confirm current recordkeeper and request your per-share cost basis by lot.

Humana (HUM): Medicare Advantage concentration and stock volatility

Humana employs approximately 100,000 people with a strategic concentration in Medicare Advantage — the private-plan alternative to traditional Medicare. This focus has produced strong stock appreciation during periods of Medicare Advantage enrollment growth, but also sharp volatility when regulatory changes, reimbursement cuts, or failed merger attempts disrupted the business.

Appreciation profile:

Volatility caveat: Humana's stock fell from above $560/share in late 2023 to below $165 in mid-2025 (a 52-week low of $163, per current data), driven by Medicare Advantage reimbursement headwinds. Employees who accumulated HUM shares in the 2020–2022 era may find that recent contributions have no appreciation — or even unrealized losses. Employees should request their lot-level cost basis from the recordkeeper and calculate the ratio using today's price, not a price from memory or a prior statement. Positions accumulated in the 2010–2013 range almost certainly still show strong appreciation despite the recent drop.

Kentucky state tax: Humana is headquartered in Louisville, Kentucky. Kentucky has a flat 4.0% income tax rate and taxes long-term capital gains as ordinary income. Humana employees receive a federal-only NUA benefit.

RSUs, ESPP, and the stock that does not qualify

All five companies in this guide offer equity compensation to corporate employees and executives — typically RSUs (restricted stock units) or employee stock purchase plans (ESPPs). The critical distinction:

• RSUs do not qualify for NUA. RSUs vest into shares delivered to a taxable brokerage account — they are taxed as ordinary income at vesting, they are never held inside a 401(k) plan, and they cannot be elected for NUA treatment. The appreciation from your vested RSUs sitting in your personal brokerage account has nothing to do with NUA.
• ESPP shares do not qualify for NUA. Like RSUs, ESPP shares are purchased through after-tax payroll deductions and held in a taxable brokerage account — never inside a 401(k) plan. They cannot be elected for NUA treatment.
• Only employer securities inside the 401(k) plan qualify. To determine whether you have qualifying employer stock, log into Fidelity NetBenefits (or your plan portal) and look for an employer stock fund (e.g., "UNH Stock Fund," "Elevance Health Stock Fund," "HCA Healthcare Common Stock") as a line item in your 401(k) balance. If you see it, you may have an NUA opportunity. If your 401(k) shows only diversified mutual funds and target-date funds, you likely have no employer stock in the plan.

State tax table: managed care headquarters and hub states

Note: Even in federal-only states, the federal NUA benefit for employees in the 32–37% bracket is very large — typically $100,000–$250,000 on positions with 6:1+ ratios. The state tax treatment means NUA doesn't add an additional layer of savings, but it doesn't eliminate the federal savings either.

Worked example 1: UnitedHealth Group IT director in Minnesota

Karen is a 58-year-old IT director who has worked at UnitedHealth Group (Optum segment) for 28 years. She is retiring this year. Her 401(k) includes a UNH Stock Fund with 3,000 shares accumulated primarily from 2009–2015 at an average cost of $43/share, giving her a total cost basis of $129,000. At $402/share, those 3,000 shares are worth $1,206,000. Her ratio is $1,206,000 ÷ $129,000 = 9.3:1.

Karen's retirement income will include a small Optum NQDC balance and Social Security at age 62, putting her expected retirement income (before 401(k) distributions) in the 24% bracket. Her current working income is in the 35% bracket.

NUA election path:

• Cost basis ($129,000) taxed as ordinary income in distribution year: $129,000 × 24% = $30,960 federal
• NUA appreciation ($1,077,000) taxed as LTCG when sold: $1,077,000 × 20% + $1,077,000 × 3.8% (NIIT) = $215,400 + $40,926 = $256,326 federal
• Total federal tax on NUA path: $287,286

IRA rollover path (eventual withdrawals):

• $1,206,000 eventually taxed as ordinary income at an assumed blended 30% rate (partially 24%, partially 32% as balance grows): ~$361,800 federal

Federal NUA savings: approximately $74,514.

Minnesota state tax (same either way): Minnesota taxes LTCG as ordinary income at rates up to 9.85%. Whether Karen takes NUA or rolls to an IRA, the state eventually taxes the entire $1,206,000 as ordinary income at her state rate. NUA provides no additional state tax advantage — but it also doesn't increase her state tax bill compared to the rollover. The entire $74,514 savings is purely federal.

Karen elects NUA in Year 1 of retirement, before Social Security adds to her income and before RMDs would push her into a higher bracket. She plans to sell the NUA stock in tranches over the following five years at approximately $215,000/year to stay within the 20% LTCG threshold and minimize NIIT exposure.

Worked example 2: HCA Healthcare nursing director in Nashville, Tennessee

Robert is a 60-year-old nursing director at a large HCA hospital in the Nashville metro area. He has worked at HCA for 15 years, joining shortly after the 2011 re-IPO. His 401(k) employer stock fund holds 3,500 HCA shares accumulated from 2012–2018 at an average basis of $55/share, for a total cost basis of $192,500. At $418/share, his HCA position is worth $1,463,000. His ratio: $1,463,000 ÷ $192,500 = 7.6:1.

Robert's retirement income will be modest — HCA does not offer a defined benefit pension. With Social Security at 62 and no other large income sources, he expects his taxable income (before 401(k) distributions) to put him in the 22% bracket in most retirement years. He is currently in the 32% bracket.

NUA election path:

• Cost basis ($192,500) taxed as ordinary income in distribution year: $192,500 × 22% = $42,350 federal
• NUA appreciation ($1,270,500) taxed as LTCG when sold: at 15% LTCG rate (within the bracket given his retirement income) plus 3.8% NIIT on amounts above $250,000: approximately $190,575 + $38,959 = ~$229,534 federal
• Total federal tax on NUA path: $271,884

IRA rollover path:

• $1,463,000 taxed as ordinary income at blended 27% (22% bracket with some 24%): ~$395,010 federal

Federal NUA savings: approximately $123,126.

Tennessee state tax advantage: Tennessee has no state income tax on wages, retirement distributions, or capital gains. Robert captures the entire $123,126 in savings — nothing is eroded by state tax on the NUA appreciation. This is the primary reason HCA employees in Nashville have a stronger NUA outcome than peers at UNH (Minneapolis) or ELV (Indianapolis) with similar ratios.

Robert is 60 at retirement, so no 10% early withdrawal penalty applies (the Rule of 55 and separation from service exemptions both cover him). He plans to sell his NUA stock gradually over 8–10 years, targeting the 15% LTCG bracket each year, before RMDs from a separate rollover IRA would increase his income.

When NUA wins for health insurance and managed care employees

• Ratio of 4:1 or higher. At 4:1 and a 32–37% federal bracket, the NUA election reliably saves five to six figures in federal tax. At lower ratios, the math is tighter and requires full modeling.
• Contributions from 2009–2014. Most employees in this sector who were contributing to an employer stock fund during the post-crisis recovery period have ratios in the 5:1 to 16:1 range — well above the break-even threshold at any federal bracket above 22%.
• High federal bracket. The higher your ordinary income tax rate, the more you save by converting appreciation from 37% OI to 20% LTCG. Directors, VPs, and executives in the 35–37% bracket have the largest savings in absolute dollar terms.
• Tennessee, Texas, or Florida residence. No-income-tax states capture the full federal advantage without state tax erosion. HCA Nashville employees, or UNH/Optum employees who retired to Florida or Texas, should model NUA as a high priority.
• Lower-bracket retirement year. If your retirement year income is lower than your working-year income, executing the NUA distribution in Year 1 of retirement (before Social Security, RMDs, and other income sources add up) can significantly reduce the tax on the cost basis portion.

When NUA doesn't help

• Ratio below 2:1. At low appreciation ratios, the ordinary income tax on the cost basis at distribution often exceeds what you'd pay by keeping the stock in an IRA and drawing it down gradually. Full rollover is typically better.
• Contributions from 2020 or later at most companies. Employees who primarily contributed to an employer stock fund after 2020 may have ratios near 1:1 or below, particularly for UNH (stock has declined significantly from its 2024 peak), HUM (same), or CI. Request the actual per-share basis before assuming NUA applies.
• No in-kind distribution option in your plan. The NUA election requires that the plan allow in-kind distribution of employer securities. This is standard for major managed care companies but should be confirmed before assuming it's available.
• Plan doesn't hold employer stock. If your 401(k) balance consists entirely of diversified funds and target-date funds, you have no employer stock eligible for NUA. This is common for employees who never opted into the employer stock fund or who rebalanced out of it.
• Already rolled over to an IRA. An IRA rollover of employer stock permanently and irrevocably eliminates the NUA election. If you rolled your 401(k) to an IRA in a prior year, the NUA opportunity is generally gone. See our guide on what to do if you already rolled over.

Questions to ask your plan administrator

1. Does my 401(k) hold employer stock (UNH/ELV/CI/HCA/HUM shares) as a distinct fund?
2. What is my per-share cost basis, broken out by lot if possible?
3. Does the plan allow in-kind distribution of employer securities (not automatic cash liquidation)?
4. What is the process for requesting an in-kind stock transfer to my taxable brokerage account?
5. Does the plan require the entire 401(k) to be distributed as a lump sum in a single tax year, or just the employer stock portion?
6. If I have pre-2006 HCA contributions (going-private event), how was that handled — was the basis reset at the 2011 re-IPO?
7. For former Express Scripts employees: what per-share basis was assigned to CI shares received in the 2018 merger?

1. UnitedHealth Group 401(k) Savings Plan — Fidelity recordkeeper confirmation: SEC Form 11-K (FY2024), UnitedHealth Group Inc.
2. Elevance Health 401(k) Plan — employer stock fund holdings: SEC Form 11-K (FY2022), Elevance Health Inc.
3. 2026 federal LTCG tax rates and ordinary income brackets: IRS Rev. Proc. 2025-32
4. IRC §402(e)(4) — NUA statutory authority (qualifying events, employer securities definition, lump-sum distribution requirement): 26 U.S.C. § 402(e)(4)
5. Net investment income tax (NIIT) — 3.8% surtax on investment income: IRS Topic 559
6. HCA Healthcare return to public markets (March 2011 IPO): HCA Healthcare Investor Relations

Tax values verified as of August 2026. Federal rates from IRS Rev. Proc. 2025-32. State rates from Tax Foundation 2026 State Individual Income Tax Rates. Stock price history from company SEC filings and financial data sources; per-share prices are approximate historical averages for modeling purposes only — request your actual lot-level cost basis from your plan administrator before making any decision.