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Centene Corp
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Good morning and welcome to the Centene 2017 Fourth Quarter and Year End Financial Results Conference Call. All participants will be in listen-only mode. After today's presentation, there will be an opportunity to ask questions. Please note, today's event is being recorded.
I would now like to turn the conference over to Ed Kroll, Senior Vice President of Finance and Investor Relations. Please go ahead.
Thank you, Rocco, and good morning, everyone. Thank you for joining us on our 2017 fourth quarter and full year earnings results conference call. Michael Neidorff, Chairman and Chief Executive Officer, and Jeff Schwaneke, Executive Vice President and Chief Financial Officer of Centene, will host this morning's call, which can also be accessed through our website at centene.com. A replay will be available shortly after the call's completion also at centene.com or by dialing 877-344-7529 in the U.S. and Canada, or in other countries by dialing 412-317-0088. The playback number for both of those dial-ins is 10115626.
Any remarks that Centene may make about future expectations, plans and prospects constitute forward-looking statements for purposes of the Safe Harbor provision under the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors, including those discussed in Centene's most recently filed Form 10-Q and Form 10-K and other public SEC filings.
Centene anticipates that subsequent events and developments will cause its estimates to change. While the company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so.
The call will also refer to certain non-GAAP measures. A reconciliation of these measures with the most directly comparable GAAP measures can be found in our fourth quarter full year 2017 press release, which is available on Centene's website at centene.com under the Investors section.
Finally, a reminder that our next earnings call will be on Tuesday, April 24, 2018. Dates for all remaining investor events in 2018 can also be found in the Investors section of centene.com.
With that, I'd like to turn the call over to our Chairman and CEO, Michael Neidorff. Michael?
Thank you, Ed. Good morning, everyone and thank you for joining Centene's fourth quarter and full year 2017 earnings call. During the course of this morning's call, we will discuss our fourth quarter and full year 2017 financial results and provide updates on Centene's markets and products. As has become our practice, we will provide commentary around the healthcare legislative and regulatory landscape. We will also bring you up-to-date on the Fidelis acquisition.
I'd like to begin with an update on the healthcare legislative and regulatory landscape. A year ago at this time, the healthcare debate was front and center in Washington D.C. It consumed more than three quarters of the legislative year and the repeal and replace effort ultimately was unsuccessful.
Since then, comprehensive reform efforts have receded and more tactical legislation has emerged, most notably, the SCHIP program being reauthorized and funded for six years. In addition, several ACA taxes have been delayed, including the health insurance fee for 2019. As part of the tax reform package that passed earlier this year, the penalties associated with the individual mandate will be eliminated beginning in 2019, which we expect to have minimal impacts on us.
We are now seeing heightened regulatory action as CMS continues to promote efforts that give states additional flexibility. This aligns well with Centene's local approach. We believe these significant developments make repeal and replace for any significant healthcare reform unlikely in 2018.
We do anticipate Congress will look at ways to stabilize the marketplace and there continues to be strong bipartisan support to implement a reinsurance program. In addition, the reinstatement of CSR funding continues to be discussed as well as greater state flexibility via 1115 and 1332 waivers. We believe these improvements have a good chance of being included in an omnibus bill that passes in the first half of 2018.
On a separate note, we're pleased to announce that Jessica L. Blume was elected to serve on Centene's Board of Directors. She was appointed to both the Audit Committee and Technology Committee. She will stand for re-election at our April 2018 Annual Shareholders Meeting.
Ms. Blume brings us strong background in technology and finance as having previously held the position of Vice Chairman at Deloitte, where she was a partner for 20 years. She served as a member of Deloitte's U.S. Executive Committee and was a member of the Deloitte Board of Directors for the maximum two terms. In addition, she served as the Chair of the Executive Compensation and Evaluation Committee as well as a member of the Finance, Governance, Strategic Investment and Risk Committees.
Now, on to the fourth quarter and full year 2017 financials. 2017 was another year of strong growth and accomplishment for Centene, capped off by the robust fourth quarter results we reported this morning.
In 2017, we added almost 800,000 members, surpassing the 12 million member mark. We grew revenues by 19% to $48.4 billion and adjusted EPS by 14% to $5.03. These results compare favorably to our initial 2017 revenue guidance of $46.4 billion and adjusted EPS guidance of $4.63 at the mid-point.
Our cash flow from operations remains strong at $1.5 billion or 1.8 times net income. During the year, we stuck to our business as usual approach. We were not distracted by the headline volatility surrounding the repeal and replace noise in Washington D.C. Our shareholders benefited as Centene's stock price increased 79%, well ahead of our five-year CAGR of 38%. We continued to enhance our diversification plan by product and geography.
Centene successfully launched an expansion effort in Medicare Advantage in four of our Medicaid states under Allwell brand. We started new Medicaid contracts in Nebraska and Nevada and one new business in 2018 in Arkansas, Illinois, Pennsylvania, and the State of Washington. Overall, win rate in Medicaid RFPs is an industry-leading 80%.
We also continue to evaluate our organization structure in an effort to be most efficient with our growth and it is important to focus on G&A and ensure we're leveraging the incremental size of the company. In summary, 2017 was another successful year and our operating momentum remains strong as we head into 2018.
Next, I'll discuss federal tax reform. We know there is a great interest in federal tax reform and what effect it will have in 2018. Specifically, with respect to how companies will deploy the potential benefit of tax reform.
For Centene, we started with our company's purpose, transforming the health of the community one person at a time. We believe we can better serve our members and customers by continuing to invest in capabilities that serve our purpose.
With that said, we intend to use the benefit of tax reform to invest in growth and employee initiatives, including leadership development programs and other training, as well as technology and processes, including digital health and analytics. All of this will help drive our mission of better outcomes at lower cost. Jeff will go into further details regarding the financial impact of tax reform, as well he'll update 2018 financial guidance.
Now, I will discuss the acquisition of Fidelis Care. In October 2017, we were granted early termination of the waiting period under Hart-Scott-Rodino. We are currently moving through the process for New York regulatory approval. This is actually a dual-track approval process. First, the typical approvals necessary for a health plan acquisition in our industry, which are progressing at a reasonable pace.
And in this case, secondly, the Catholic Church is working with New York State officials on the mission of the foundation it intends to set up with the proceeds. Unfortunately, this portion of the process appears to be taking longer than expected. We continue to work towards an April 1, 2018 closing date. The initial integration planning is underway and going extremely well.
Next on the medical costs, including flu. The latest data indicate that flu season is more intense than last year. In my presentation at the Investor Conference in early January, I indicated we saw flu peak around the holidays. Subsequently, we saw flu trend up again to a second higher peak for our membership. We have not seen this happen in over five years. It clearly is higher than expected and a potential headwind for the first quarter. However, we remind you, we view flu trends as episodic and not indicative of our ability to manage overall medical costs. Importantly, we continue to see as well as anticipate overall stable medical cost trends consistent with our expectations in the low single-digits.
Moving on to market and product updates, first, we'll discuss recent Medicaid activity. New Mexico. Last month it was announced that our New Mexico subsidiary Western Sky Community Care was one of three vendors awarded a statewide contract for the Centennial Care 2.0 Program.
New Mexico's current program provides integrated Medicaid Managed Care coverage, including long-term support services and behavioral health to nearly 700,000 beneficiaries. We are particularly pleased to have been awarded this, as it was a re-procurement of an existing contract and Centene was not an incumbent. While there have been appeals and suits, we believe they're unfounded and will not ultimately be successful. We expect this contract to commence on January 1, 2019.
Centene currently operates in New Mexico through our Centurion subsidiary as the sole provider of correctional health services in 11 facilities throughout the state.
Illinois. In January, our Illinois subsidiary, IlliniCare, began operating under a new statewide contract serving Medicaid beneficiaries and needy children. Centene previously operated in 12 counties in the state. Under the expanded contract, we will operate in all 102 counties and materially increase our membership and revenue. Our new members should all be enrolled by April 1 with the exception of Foster Care, which is expected to commence on July 1. We were pleased to be the sole source provider for the Foster Care program.
Pennsylvania. In January, we began serving beneficiaries enrolled in Pennsylvania's new Long Term Care program in the Southwest zone. The remaining zones' start date vary and will be fully implemented by January of 2020. So far, our membership has come in above our expectations.
Washington. In January, Centene began providing managed care services to beneficiaries enrolled in the state's Apple Health Fully Integrated Care program in the north-central region of the state. This was a re-procurement of our existing contract and now integrates behavioral health into the program.
Arkansas. In February, we began managing a non-risk Medicaid special needs population comprised of individuals with high behavioral health needs and individuals with developmental and intellectual disabilities. In October 2017, our Arkansas joint venture with Mercy Health and LifeShare received a license to become a risk-based provider organization. Approved risk-based provider organizations will manage and take full risk of this population beginning in January of 2019.
Now on to Medicare. At year end, we served over 330,000 Medicare and MMP beneficiaries. We are pleased with the operating performance of the Medicare Advantage book of business in 2017. We applied the insights we gained in 2017 towards Centene's 2018 Medicare Advantage and D-SNP plans.
In January, we began operating MA and D-SNP plans in eight new Centene Medicaid states. These plans will launch under Allwell brand and are all eligible for a premium bonus under our 4 Star parent rating in 2018. The initial metrics for 2018 membership growth are in line with expectations. Upon the close of the Fidelis deal, we will also be serving Medicare Advantage members in New York. Over the long-term, we continue to expect our Medicare Advantage product to drive over 20% of our annual growth rate.
Moving on to Health Insurance Marketplace, at year end, we served just under 1 million exchange members. This represents a sequential decline of approximately 60,000 beneficiaries due to normal attrition. This was in line with our expectations. The Marketplace business performed well in the fourth quarter and full year of 2017. Our 2018 exchange focus remains on providing high-quality affordable health care to low-income individuals. We began offering exchange products in three new states in 2018: Kansas, Nevada and Missouri.
In January, we had over 1.6 million paid exchange members. The key demographics of these members, including age, gender, financial assistance and medal tier remain consistent with the comments made at our December Investor Day. This includes a modest shift from silver to bronze plans, which was anticipated. Upon the closing of Fidelis Care transaction, we will be offering exchange products in 16 states, up from 13 states last year.
Shifting gears to our rate outlook, for 2017 our composite Medicaid rate adjustment was an increase of approximately 1%. We are also expecting a composite Medicaid rate adjustment of an increase of approximately 1% in 2018. Separately, last week, CMS issued the 2019 Advance Notice and preliminary Medicare Advantage rates appear to be in line with our expectations.
In conclusion, 2017 was another successful year for Centene. Our strong fourth quarter result sets the stage to maintain our positive momentum into 2018. Centene has been and continues to be a growth company with expectations of growing both top and bottom line by double-digit percentages. We expect our margins to continue to expand as we maintain focus on process efficiencies through automation and increasing our scale.
Our pending Fidelis acquisition is expected to create significant value for Centene's shareholders and Fidelis' stakeholders, as well as provide high-quality, low-cost health care services to the most vulnerable populations in New York.
We have proven our ability to acquire and effectively integrate large acquisitions. We are confident in our ability to successfully integrate Fidelis. We are optimistic about our future and ability to continue to extend Centene's leadership position in government-sponsored health care.
Before I turn the call over to Jeff to provide further details on our fourth quarter and full year 2017 results, I would like to give you a heads up regarding a change in our reporting format. Due to our increasingly diversified platform and emphasis on product categories, we will be adding a supplemental revenue disclosure by product category beginning in the fourth quarter of 2018. Also, we will no longer be breaking out membership by state.
We thank you for continued interest in Centene, and I will now turn the call over to Jeff.
Thank you, Michael, and good morning. Earlier this morning, we reported strong fourth quarter and full year 2017 results. For the full year, total revenues were $48.4 billion, an increase of 19% over 2016, driven by the full year of Health Net's results, growth in the Health Insurance Marketplace business and product and market expansions in 2016 and 2017. Adjusted diluted earnings per share for the full year 2017 were $5.03, an increase of 14% over last year and 9% higher than our initial 2017 guidance midpoint.
Before I discuss the fourth quarter results, I would like to spend a few minutes and discuss tax reform. As Michael previously mentioned, we have adjusted our full year 2018 guidance to reflect tax reform, which is expected to benefit net earnings and cash flow by approximately $280 million in 2018. This is before additional investments of $60 million after tax to support growth and employee initiatives during the year, investments in technology and analytics and enhancing our capabilities to serve our members and state customers.
I'd also like to highlight that based on our expectations for the year, the benefit of the lower tax rate was not limited by minimum MLRs in our commercial markets. We will discuss the revised 2018 guidance, including the effective tax reform in a few minutes, but first, let me discuss the fourth quarter results.
We reported strong fourth quarter results with total revenues of $12.8 billion, an increase of 8% over the fourth quarter of 2016 and adjusted diluted earnings per share was $0.97 this quarter compared to $1.19 last year. The decrease in adjusted diluted earnings per share compared to the prior year is the result of significant investment in growth initiatives in the fourth quarter of 2017 associated with the Marketplace and Medicare businesses and the impact of flu.
We spent $0.26 per diluted share on business expansion costs in the fourth quarter and $0.50 per diluted share for the full year 2017. For the fourth quarter 2017, adjusted diluted earnings per share excludes the following items: lower tax expense of approximately $125 million or $0.71 per diluted share associated with the re-measurement of our net deferred tax liabilities to a 21% tax rate as a result of tax reform that was passed in December 2017.
$40 million or $0.14 per diluted share, associated with a contribution to the company's charitable foundation in connection with the benefit from tax reform, additional expense of $22 million or $0.08 per diluted share associated with the lack of CSR funding by the federal government in the fourth quarter, amortization of acquired intangible assets of $0.14 per diluted share, and acquisition-related expenses of $0.02 per diluted share.
Let me provide some more details for the quarter. Total revenues grew approximately $900 million year-over-year primarily as a result of growth in the Health Insurance Marketplace business, the expansions in new programs in many of our states in 2016 and 2017, including the expansion of the Missouri contract and the startup of our Nebraska and Nevada health plans in 2017.
This growth was partially offset by the fourth quarter of last year benefiting from $195 million of revenue associated with the MLR amendment in California, the one-year moratorium of health insurer fee in 2017 and lower 2017 membership in the commercial business in California as a result of margin improvement actions taken last year.
Moving on to HBR, our health benefits ratio was 87.3% in the fourth quarter this year compared to 84.8% in last year's fourth quarter, and 88% in the third quarter. The increase year-over-year is primarily driven by the benefit recorded last year related to the minimum MLR amendment in California. This decreased last year's HBR by approximately 170 basis points.
Additionally, the fourth quarter 2017's HBR was negatively affected by the additional expenses associated with the lack of CSR funding, higher flu costs, the premium rate reduction in our Medicaid Expansion business in California, effective July 2017, and performance of newer expanded markets, which initially operate at a higher HBR.
Sequentially, the 70 basis point decrease from the third quarter is primarily attributable to favorable performance in Medicaid, including premium rate adjustments as well as favorable performance in our Marketplace business. This was partially offset by increased flu costs of 30 basis points compared to the third quarter and the previously mentioned CSR expense, which accounted for a 20 basis point increase in the HBR for the fourth quarter.
The Marketplace business performed well in the fourth quarter and full year 2017. As previously mentioned, during the fourth quarter, we recorded additional expense of $0.08 per diluted share, recognizing the effect of the federal government not funding the CSRs. This primarily represents states, where we have receivable positions on CSRs at the end of the year. For the majority of our states, we have received CSR payments for 2017 that represent our full year CSRs.
As Michael previously mentioned, for January 2018, we have over 1.6 million paid members, which is higher than our expectations we discussed at our December Investor Day. We have updated our guidance to reflect our revised membership expectations.
Moving on, our adjusted selling, general and administrative expense ratio was 10.5% in the fourth quarter this year compared to 9.4% last year and 8.9% in the third quarter of 2017. The increase in the ratio year-over-year is due to increased business expansion costs and the revenue recognized in the fourth quarter of 2016 related to the minimum MLR amendment in California, which reduced the prior year adjusted SG&A expense ratio. The sequential increase is due to the increased cost associated with the open enrollment periods for both the Medicare and Marketplace businesses.
We recognized an income tax benefit of $55 million in the fourth quarter of 2017 due to Income Tax Reform. Excluding the effective tax reform and the charitable contribution, our fourth quarter tax rate would have been 40.9%.
Now onto the balance sheet, cash and investments totaled $10.1 billion at quarter-end, including $310 million held by unregulated subsidiaries. Our risk-based capital percentage for NAIC filers continues to be in excess of 350% of the authorized control level.
Debt at year end was $4.7 billion, including $150 million of borrowings on our revolving credit facility. Our debt-to-capital ratio was 40.3%, excluding our non-recourse mortgage note compared to 43.7% at last year end and 41.2% at the end of the third quarter 2017. We are pleased with the continued deleveraging of the company by 340 basis points during the year.
Our medical claims liabilities totaled $4.3 billion at year end and represents 41 days in claims payable compared to 42 days last quarter. Cash flow provided by operations was $450 million in the fourth quarter and $1.5 billion for the full year 2017 or 1.8 times net earnings.
Next, I would like to provide an update on the Fidelis transaction. As Michael mentioned, we continue to work toward an April 1 transaction closing and expect to fund the transaction with approximately $2.3 billion of equity and $1.6 billion of debt. As we have indicated in our earnings release today, we have updated our guidance to change the equity issuance timing from February 1 to March 1. Again, these are guidance assumptions and the ultimate timing of the debt and equity financing will be subject to market conditions.
Lastly, turning to 2018 guidance, we have updated our 2018 annual guidance for several items and have included a table in our press release issued this morning to provide more clarity on the changes. We have updated our guidance for the following: an increase in our revenue at the midpoint of approximately $700 million associated with the higher membership expectations on the Health Insurance Marketplace business.
The additional membership also increased our GAAP and adjusted diluted earnings per share by approximately $0.14. The increase in revenue was partially offset by the effective tax reform, which decreased our revenue by over $100 million associated with the lower tax rate gross-up on the health insurer fee in the Medicaid business. This revenue adjustment has no effect on net earnings.
Additionally, as previously mentioned, we expect lower tax expense of approximately $280 million or $1.38 and $1.58 per diluted share impact on GAAP and adjusted diluted earnings per share respectively associated with tax reform. This is before the additional $60 million after tax or $0.30 per diluted share for investment in employees' technology and systems we previously discussed.
Lastly, as discussed previously, we have revised our share count to reflect the change in the equity issuance timing for the Fidelis transaction financing. This increased both our GAAP and adjusted diluted earnings per share by $0.06 per diluted share.
In summary, our updated full year 2018 guidance for revenue and earnings per share is as follows: total revenues between $60.6 billion and $61.4 billion, GAAP earnings per share of $5.91 to $6.25, and adjusted diluted earnings per share of $6.95 to $7.35.
Lastly, a quick comment on the quarterly spread of our earnings. As a result of the shorter open enrollment period for the Marketplace product and increased membership, peak membership is earlier than last year. As a result, we expect the distribution of our earnings between the first half and second half of the year to be similar to 2017. However, we expect slightly more earnings in the first quarter this year versus the second.
In summary, we are pleased with the company's fourth quarter and full year results and the momentum we carry into 2018.
That concludes my remarks. And, operator, you may now open the line for questions.
Thank you. We will now begin the question-and-answer session. Today's first question comes from Steve Tanal of Goldman Sachs. Please go ahead.
Good morning, guys. Thanks for taking the question.
Good morning.
I was wondering if you would just comment on sort of the tax reform net accretion guidance and what sort of is assumed there for potential offsets. I guess the one that's top of mind for us, a bit of a concern, is just the New York State windfall tax that was proposed. Any thoughts there on what's in the numbers versus not?
Yeah, I think – Jeff, do you want to start, then I'll pick up?
Yeah, I mean, I think right now that is specific to New York and I think there was something in California. Those haven't passed, those aren't law at this point in time. So we have not projected anything in that other than the lower federal tax rate that's in our guidance today.
So again, it's early. We'll have to wait and see what the impact is on both the commercial and Medicaid business. But as I stated in our Investor Day, longer-term, we see opportunity in the Medicaid business. On the commercial side, it really depends on the competitive dynamics.
And there are (30:56) some federal laws and legislation on the amount of tax that a state can charge on those types of products, specifically Medicaid. And that was set up so they don't find a way to fund the Medicaid to their share of it through taxing. So I think this has a long way to play out and it's not something that we see having any short-term or longer-term effect on us.
Understood. That's very helpful. And just lastly for me, maybe on Marketplace, really strong numbers there, upside to enrollment. Curious to know from your perspective, Michael, where are you guys seeing that? Or how much of that growth is about competitors backing out at this stage? Where is that growth really coming from?
Well, I think we've retained about 80% of the population we had from last year. And I think we have the right networks, we have the right systems and capability to manage it and develop that reputation. We've entered some new states; Nevada and Missouri, we mentioned among – this is the third one. And so some of it's coming from those new states. If people are backing out and we're in that state, we obviously will pick up some of that membership. But most of it, I believe, is on our own account and how we're doing things and the reputation we have in the marketplace with the all-better (32:13) franchise.
Got it. Thank you.
And our next question comes from Josh Raskin of Nephron Research. Please go ahead.
Hi. Thanks. So good morning, guys.
Good morning.
Morning, Michael. So the first thing that sort of jumped out, it just sounds like the first quarter numbers you're expecting a little bit better than what the Street was expecting and better than the second quarter. I guess I understand that the Marketplace is off to a better start, but I'm surprised just based on flu, is it just simply you took bigger flu accruals in the fourth quarter to account for that because you knew it was coming when you closed the books? Or what? I'm curious why the 1Q numbers are strong.
Yeah, a couple things, Josh. I'd say, first, we have more commercial business mix than we used to have several years ago. So it used to be the first quarter had the least amount of earnings in specifically in the Medicaid business, but we've kind of flipped because of the entrance into the Marketplace and other commercial markets. And so with the open enrollment happening earlier this year, we do see higher membership coming on earlier than we did the previous year. And as we've mentioned, the earnings profile of Marketplace is it makes more money in the first quarter than it does in the fourth quarter.
So I think that's really driving the shift, is really the higher membership and an earlier date and the economic dynamics in the Marketplace product, where you actually make more money in the first quarter than any other quarter throughout the year because of deductibles, right?
So I think that's the phenomenon that we're trying to talk about, and it's just a little bit different than last year because the peak membership happens a couple of months earlier, right?
And I think relative to the flu, I mean, we've anticipated some of it. I talked about the second peak. So it's one element in total medical costs, and we have seen that there tend to be offsets. And I think part of the benefit of our scale and size and the population we serve, Josh, is that we do get offsets.
And I've said there is a little headwind on the flu. We recognize it, we monitor it carefully. We've had flu prevention programs and things. In some states it's higher than others. We see where it is higher it's a function of physician cost and some Tamiflu and some testing for the flu. So it's more the ambulatory-type costs that we're seeing on it, which is much more manageable.
Got you, got you. That makes sense.
Yeah. And just, I mean, one other thing. One month does not make a quarter or a year, right? I mean, we provide annual guidance, so...
Yes. That's fair. That's fair. And then just a question on the sustainability of this tax reform benefit. I was also surprised to hear you say none of it's getting caught up in the minimum MLRs for the California commercial business, which was not surprising, but are you not seeing any state mechanisms? I know certain states, Texas for example, you guys are always paying a big rebate there. Are any of the states looking to – and I know we talked about California and New York with these windfall taxes but just more specifically, the mechanics around how your contracts exist today, do you not think any of that benefit flows back to the states? And then I'd be curious to get your perspectives on long-term. Do you think the states, if they're not capturing it, do you think they come back and try?
I think I commented earlier on there are some legislative constraints. I might also comment, Josh, we encourage states to do what we do in Texas. We really like that program. We'll get the actuarially sound rates. We have the highest quality scores there, and they see that we're very efficient with the – when you're, say, giving them checks for $100 million and that, which is a very balanced way to do it versus just cutting across the board. And so I think you'll hear states talk about it as they go through budgets and things, but I'm not making any decisions on the basis that that's going to happen.
Okay. All right. Thanks.
And our next question today comes from Chris Rigg of Deutsche Bank. Please go ahead.
Hi. Good morning. Just wanted to ask about the -
Good morning.
Good morning, guys, just the SG&A ratio in the fourth quarter. I mean, from afar it looks like there may have been some discretionary spending in there that was maybe not planned, but maybe I'm wrong. Just want to get a sense for how you looked at investment spending in the fourth quarter. Thank you.
No. I think if you go back to what we said at our Guidance Day, we said we expected the SG&A ratio to be above 10.5%. I'm, obviously, excluding the charitable contribution. I'm looking at the adjusted SG&A ratio.
So really, it was kind of a preview for the costs that we expected to incur on the Marketplace and the Medicare open enrollment period. And if you recall, the government restricted their spending specifically on the Marketplace and so we kind of stepped in and filled the gap. And we added those dollars somewhere around the second and third quarter. So that was really new spending for us. When you look at our original guidance for 2017, that wasn't included, and we effectively took steps to invest in those products. And, obviously, with the results that we have, it's been very successful.
Yeah. The return on that investment in G&A was very worthwhile.
Understood. And then I apologize for coming back to the MLR floors and the dynamic there, but I just want to make sure, is there at all a component or a dynamic there where, because in certain states the statutory entity includes both Medicaid and the commercial, that helps keep you under the threshold? Or is that not the case? I'm trying to think about that in the context of the overall profitability of the Marketplace business generally. Thanks.
Well, I mean, I think that's one of the reasons why it's a little more complicated than you would think right off the cuff is because, in general, the basis that most states would have to leverage some form of tax would be the statutory financial statements. And you're right, there could be multiple products in each one, so it's not as cut and dried as everybody may seem to think.
Great. Thanks a lot.
And our next question comes from Sarah James of Piper Jaffray. Please go ahead.
Thank you. It looks like the Florida invitation to negotiate was put out a few days ago. Could you just update us on how Centene did on that versus your existing regions? And one of your competitors was talking about possibly a protest, so just would love your thoughts on whether or not there was anything unusual in this RFP the way it was set up. I know some states like Ohio had problems in the past, so just was there anything unusual in this one?
Yeah, I'm not going to comment on what we've been asked to do and not do, that's up to the states to comment on it. I will tell you that I'm not unhappy with what they've asked us to do. And that as it goes forward, I think the world is watching individuals more and more who are not successful for various reasons filing protests, and there's a mechanism and it's their right. And we'll let those things play out. And – but we're confident that our business in Florida is sound, and we've delivered on their expectations, so we'll continue to do well there. Chris (39:57), anything you want to add?
No, I would just add, Michael, and reiterate that we were real pleased with the way that the process is turning out so far and there's more to come.
Great. And just a follow-up on guidance. I appreciate you walking through a few of the moving pieces on MLR guidance as we think through the bridge from this year to next year. Just wanted to clarify if there was a step-up or step-down in expected flu costs in 2017 to 2018; and then if there's any books that are anticipated to improve. So for example, I know that Pennsylvania ABD is relatively new, so has that matured yet or is it still ramping?
Yes. With respect to the flu, I think, Michael kind of covered that. Flu is only one component of medical costs. We're talking about one month out of an entire year right now. That's all we have really information on, a little over a month. And so I think I'll just leave that there.
And your second question, I mean, we're obviously – I mentioned in the fourth quarter results the commentary about the higher HBR and our new plans. And yeah, we absolutely expect improvements in, I would say, the Nebraska, Missouri, Pennsylvania. Usually, there's continuity in care provisions and new programs, and so if there's nothing different than what we have historically said that they run higher HBRs for the first six to nine months and then we expect those to come down with medical management initiatives, so nothing new there.
I might just add, Sarah, that we book a higher number even in what may be calculated, just in the interest of abundance of conservatism.
Thank you.
And our next question comes from Kevin Fischbeck of Bank of America Merrill Lynch. Please go ahead.
Great. Thanks. I wanted to go back to a comment you made about 2019 and the thought that the individual mandate repeal is not going to have a meaningful impact on the business. Just wanted to get some color from you guys around why that would be the case, I guess first on the exchanges. And then second, obviously, one of the things that kind of surprised people when Medicaid Expansion went on was the Woodwork Effect and all the people who came out to get insurance there. Thoughts about how that mandate impacted the potential Woodwork dynamic and why that wouldn't be a headwind going forward.
Well, sure, Kevin. I think our population, we have really focused on sticking to our knitting, as the cliché goes, we're very focused on a given level of socioeconomic that's consistent with our population. And that population gets full reimbursement or full coverage for those costs. And so therefore, it's not a question of them having to join or what it's going to cost them because they get the coverage. And so we said it will have a minimal effect on us, we won't say it won't have any, but I think our growth in the overall marketplace and how we're executing on it, we see no reason why that's going to change in 2019. And as I said, the individual mandate, it has very little impact because of the level of coverage our population will receive.
And I guess on the Woodwork Effect, how do you think about that? If not the mandate helping that then what kind of drove that effect?
Well, I think just the overall impact of the plans and what we're able to offer and once again, the socioeconomic coverage. I mean, the premium subsidies are in the legislation, so when they did away with the CSRs, our population continued to be able to enroll with subsidies through the premium. Now it's been well publicized; it'll cost the government more money that way. And that's why I think they're going to reconsider CSRs going forward. So as people came out and wanted the coverage, the population we serve still had the premium subsidies to protect them.
Okay. And I guess this guidance is actually pretty strong guidance. I'm used to you guys providing guidance in December and then basically just kind of reaffirming it when you report the Q4 results because it hasn't been that different. Obviously, tax reform is a unique item and the Fidelis timing also kind of unique items, so you've done things like that in the past on moving guidance on timing. But I don't remember the last time you actually raised guidance on a core basis so quickly, so just wondering kind of what gave you the confidence this early in the year to do that? And how you think about the momentum?
Yeah, I mean, I think if you go back, it's just really membership expectations and actual results that we have so far on the Marketplace business. I mean, back in December, I think, we kind of guided to a number of around 1.3 million paid members. And now we're looking at something greater than 1.6 million. So from that perspective, it's just more time has passed and we have certainty on the number of enrollees, and we're obviously – it's been a very successful open enrollment for us. And so we felt we needed to change guidance for the additional revenue and earnings that that's going to deliver.
I'll add a little more color to it. At a conference in January, I estimated 1,450,000 people, but what's happened here is you typically would see in the 70s conversion for most people to sign up and actually pay a premium. Well in this particular year, we had a whole lot more people. I'm not going to get super specific, but we had a much higher percentage convert and pay the premium. And so when you see that happening, it says they wanted the insurance and it gives you some confidence that it's going to stick.
All right. Great. Thank you.
And our next question today comes from Matt Borsch of BMO Capital Markets. Please go ahead.
Maybe I could just continue along on that thread on the ACA exchange membership. So you say you're looking at about 1.6 million. I guess, what I'm wondering is how are you measuring and what kind of fix do you have on the composition of that membership relative to your typical profile of low income, mostly subsidized members.
Yes, I would say that as we said at our Investor Day and I'll restate it that everything we've seen, the profile of the membership is basically where we have historically received in that. There was a few percent shift from the silver to the bronze, but other than that, the gender, age, every aspect of it is consistent with what we historically have attracted.
And as you find yourself in markets where you're the only carrier providing coverage, to what extent are you having to fend off maybe regulatory pressure to change your network to make it fit a broader spectrum of potential insureds?
No, I would say that we are what we are. We're basically the Medicaid coverage. We have some Medicare now that is also looks to those traditional providers, and we're not going to try and be more than that. Now I want to remind people, while we're the, in some markets, the only exchange product, there are other individual products that may be available through some insureds-type products. But from an exchange standpoint, no, there's been no pressure from the states, and we would be very quick to resist any pressure to change and move away from what is our traditional membership.
Thank you.
And our next question today comes from Dave Windley of Jefferies. Please go ahead.
Hi. Good morning.
Morning.
Shifting to MA, I'm curious if you could describe kind of your level of satisfaction with the enrollment that you've seen in some of your expansion markets for Medicare Advantage and then also your reaction to CMS's proposed change to the calculation on crosswalking, if you think that'll stick and how you might mitigate your 2019 Stars impact if that is not available to you. Thanks.
I think there's several factors. We've been satisfied that we're continuing to build the Medicare as we did the early stages of the exchange products, and we're sticking to that methodical growth and being very careful about it. And it's growing at said (49:23) levels. And it's not just that, it's between now and the end of the year because once again there's programs to enroll individuals as they become age eligible to move into Medicare. So that aspect of it is not a problem.
Relative to the crosswalk, that's not been fully defined, and we continue to talk to CMS about the calculations and how they reach the level of our Stars. And there was some double jeopardy. And I remind everybody, this was before Centene owned Health Net that this all occurred. So we're working through it, and I think we're finding that CMS is listening to our arguments. And it still has a little ways to play out.
Would you expect those conversations to conclude before you submit bids for 2019? Or what do you think the timing would be on having clarity on that?
Oh, I think we will have some clarity in the very near future. But 2019, we'll look at our bids, what's appropriate to bid, not just based on that.
Sure. All right. Thank you.
Let me just – I want to be very careful. This is a one-year issue for 2019, and that's the benefit of having our scale and size. When you're a $62 billion company, you can look at it and say there are offsets to that one year. And so as I look at it, if it was a multiple year and a big issue, then it would be something else. But right now it's well within our scope of copability.
Got it. Thank you.
And our next question today comes from A. J. Rice of Credit Suisse. Please go ahead.
Thanks. Hello, everybody.
Good morning.
First, Michael, you mentioned the waiver process and states going through that, and I know we have two states, Kentucky and Indiana, that have so far been approved to add a work requirement and others are looking at it. What is your view on that? And are there particular aspects to those waivers that you're trying to make sure that are included as they roll those out?
Well, we're working carefully with the states and talking about it. I want to be careful when I'm talking to states that they don't hear about something that they haven't announced. But I will tell you this, on the work, I'm an advocate of it. When we do what we do, we look at what's sound public policy, and looking at where we are and what's affordable and where things are, I think it would be very important to do that. And as they become successful in the workforce, they can move over and join our exchange program.
Okay. Just a point on the quarter, we saw the Services business grow, I think, 9% after two quarters, where year-to-year it was down. Is there anything to highlight there? And do you expect to see growth in the Services business in 2018?
Jeff, you want to take that?
Yeah. A couple things. I would say the Services business is a little bit lumpy on the top line, really driven by contract reconciliations for the Centurion business, the Fed Services business. The other thing is we did have a small acquisition where we added cystic fibrosis to our specialty pharmacy company, so that will add a little bit of revenue. But I think I mentioned at our Investor Day we're looking at maybe a couple hundred million dollar growth year-over-year, 2017 to 2018.
Okay. Thanks a lot.
And our next question today comes from Justin Lake of Wolfe Research. Please go ahead.
Thanks. Good morning.
Good morning.
Wanted to follow up on your comments around the Fidelis deal. The discussion around the foundation is really helpful. The other thing that was in the Governor's budget was looking to collect I think it was $750 million from conversions, M&A, et cetera, kind of like some kind of not-for-profit tax on conversion. So can you talk a little bit about this? From the perspective that they're looking for $750 million, we don't know how they're going to calculate it. I don't know if it's per deal.
And then the Fidelis agreement indicates that they have a maximum number set aside in terms of proceeds, where I think they said anything above $375 million less than proceeds could break the deal. So I'm curious, if it is $750 million, how you would look to bridge that, potentially just increase the purchase price et cetera. So any kind of comments around those two things would be really helpful. Thanks.
Sure. First, I'll tell you that those are negotiations between the cardinal and seven other archbishops and so I want to be very careful to not interject myself in the middle of it. That we're going to pay them $3.75 billion for the business and I'm not going to increase that, okay?
Now if they decide they want to pay a little bit more, which might make sense from their perspective, to get the balance of that money, great. So I think at this point, I'm going to let them and the Governor and the AG's office have that negotiation. I know it's ongoing. And the best thing I can do is stay out of it. Because we're working through the other side of it very effectively and we're pleased with how that's going. Chris Koster has been driving that for us. He's a former AG here in Missouri who has joined our staff, and is very effective in dealing with regulatory issues.
So I'm trying to be as diplomatic as I can and tell you that I think the church has every interest to get this done because are they better off getting nothing or some significant portion of the $3.75 billion. I think the difference between the $750 million you quoted and I'm not going to give any credence to that and the $375 million is a mere $375 million.
Right, no, that makes sense. Then just to be clear, if there's a delineation between the foundation, which is always kind of set up with any (56:34) kind of not-for-profit conversion like there was with Empire when it made the conversion to for-profit status and the $750 million, right? This is a tax on the top. Whatever is left would be expected to go into a foundation and that's a separate...
Justin, this is very different. They went from a not-for-profit to a for-profit status. This is a not-for-profit company. Which one, there is no conversion because you're buying assets, okay?
Right.
So it's the matter of some negotiations where they say they have a foundation that owns the plan so to speak, in a manner of speaking. And so it's now converting from that asset to a cash, and the state may see this as an opportunity in discussions to say we should get some small portion of that, and that's fine. But it's very different than an Empire conversion, and it's just very distinctly different.
Yeah, that's helpful. Thanks, Michael.
Thank you.
And our next question comes from Gary Taylor of JPMorgan. Please go ahead.
Hi. Good morning.
Good morning.
I just want to ask Jeff a question about prior period developments in the quarter. It looks like that rolling figure dropped about $101 million sequentially and I just wanted to see if there was any color. Does that imply 4Q development was negative or it was just less positive than 4Q of 2016? Could you help us out?
The rolling figure is a 12-month number, I believe, right?
Right.
So but at the end of the day, again, the way we look at development is consistency as a percentage of medical costs, and I think we've historically been into the 1.1% to 1.2% of medical cost as development. So in general, there's nothing unusual there is what I would say.
It's been rising for seven quarters in a row, and it's dropped off about $100 million sequentially. That's just why it jumped out. But there's nothing you'd call out?
Yeah. No. Nothing specific.
Okay. Oh, one other thing. I was getting buzzed in my ear when you made the comment about flu for the fourth quarter. Did you say there was 30 basis points of MLR impact on the 4Q 2017 numbers? Or did I write that number wrong?
If you're bridging from the third quarter of 2017 to the fourth quarter, it's 30 bps.
Oh, sequentially. Okay.
Yes. Sequentially is probably the number I quoted.
Yeah. Thank you.
This concludes our question-and-answer session. I'd like to turn the conference back over to Mr. Neidorff for any closing remarks.
Well, I want to thank you all for your participation, and I look forward to talking to you. I'll close by saying that I think the team is very optimistic. We believe that the company is in a good place with a lot of assets that we can continue to serve our investors well. So look forward to talking to you next quarter. Thank you.
And thank you, sir. Today's conference has now concluded, and we thank you all for attending today's presentation. You may now disconnect your lines, and have a wonderful day.