Delaware | 1-31719 | 13-4204626 |
(State of incorporation) | (Commission File Number) | (I.R.S. Employer Identification Number) |
200 Oceangate, Suite 100, Long Beach, California 90802 |
(Address of principal executive offices) |
MOLINA HEALTHCARE, INC. | |||
Date: | October 27, 2016 | By: | /s/ Jeff D. Barlow |
Jeff D. Barlow | |||
Chief Legal Officer and Secretary |
Exhibit | |
No. | Description |
99.1 | Press release of Molina Healthcare, Inc. issued October 27, 2016, as to financial results for the third quarter and nine months ended September 30, 2016. |
• | Net income per diluted share for the quarter of $0.76. |
• | Adjusted net income per diluted share for the quarter of $0.85. |
• | Net income per diluted share for the quarter up 31% over second quarter 2016. |
• | Adjusted net income per diluted share for the quarter up 27% over second quarter 2016. |
• | Total revenue for the quarter of $4.5 billion, up 26% over third quarter 2015. |
• | Aggregate membership up 22% over third quarter 2015. |
• | Improved profitability among products other than the Marketplace, partially offset by lower profitability for the Marketplace product. Excluding adjustments related to 2015 dates of service, the medical care ratio for all products combined (excluding Marketplace) declined to 89.6% in the third quarter from 90.3% in the second quarter. The medical care ratio for the Marketplace program (also excluding adjustments related to 2015 dates of service) increased to 89.0% in the third quarter from 79.7% in the second quarter. Although third quarter results for the Marketplace business were lower than anticipated, we believe that Marketplace performance for full year 2016 dates of service |
• | Improved administrative efficiency. Our general and administrative expense ratio fell to 7.6% in the third quarter of 2016 from 8.1% in the second quarter. |
• | Lower effective tax rate. The benefit of approximately $5 million in discrete items reduced our effective tax rate to 54.0% in the third quarter of 2016, from 59.8% in the second quarter. |
• | The ultimate savings to be realized from various cost savings initiatives and the speed at which such savings will be realized. |
• | Medicaid rate increases (excluding Medicaid Expansion) of approximately 3.0% in California (effective July 1, 2016); approximately 2.5% in Puerto Rico (effective July 1, 2016); approximately 3.0% in Texas (effective September 1, 2016); and approximately 4.0% in Florida (effective September 1, 2016). All rate changes are consistent with our previous expectations. |
• | Medicaid Expansion rate decreases of approximately 11.0% in California (effective July 1, 2016) and approximately 2.0% in Ohio (effective July 1, 2016). All rate changes are consistent with our previous expectations. |
• | The implementation of a medical care ratio floor of 86.0% for the South Carolina Medicaid program effective July 1, 2016. |
• | Declining margins for our Marketplace business during the second half of 2016 due to normal membership attrition; the addition of higher cost members through the special enrollment process; higher costs as members reach the limits of the cost-sharing provisions of their insurance coverage; and increasing utilization as members become more engaged with our care networks. |
• | the success of our profit improvement and cost-cutting initiatives; |
• | uncertainties and evolving market and provider economics associated with the implementation of the Affordable Care Act (the “ACA”), the Medicaid expansion, the insurance marketplaces, the effect of various implementing regulations, and uncertainties regarding the Medicare-Medicaid dual eligible demonstration programs in California, Illinois, Michigan, Ohio, South Carolina, and Texas; |
• | management of our medical costs, including our ability to reduce over time the high medical costs commonly associated with new patient populations; |
• | our ability to predict with a reasonable degree of accuracy utilization rates, including utilization rates in new plans, geographies, and programs where we have less experience with patient and provider populations, and also including utilization rates associated with seasonal flu patterns or other newly emergent diseases; |
• | our ability to manage growth, including maintaining and creating adequate internal systems and controls relating to authorizations, approvals, provider payments, and the overall success of our care management initiatives; |
• | our ability to consummate and realize benefits from proposed acquisitions, including the pending Aetna-Humana Medicare Advantage divestiture transaction; |
• | our receipt of adequate premium rates to support increasing pharmacy costs, including costs associated with specialty drugs and costs resulting from formulary changes that allow the option of higher-priced non-generic drugs; |
• | our ability to operate profitably in an environment where the trend in premium rate increases lags behind the trend in increasing medical costs; |
• | the interpretation and implementation of federal or state medical cost expenditure floors, administrative cost and profit ceilings, premium stabilization programs, profit sharing arrangements, and risk adjustment provisions; |
• | our estimates of amounts owed for such cost expenditure floors, administrative cost and profit ceilings, premium stabilization programs, profit-sharing arrangements, and risk adjustment provisions, including but not limited to cost-plus reimbursement for retroactively eligible members in New Mexico, the Medicaid expansion cost corridors in New Mexico and Washington, and any other retroactive adjustment to revenue where methodologies and procedures are subject to interpretation, or are at least partially dependent upon information about the health status of state or federal program participants who are not Molina members; |
• | the interpretation and implementation of at-risk premium rules regarding the achievement of certain quality measures, and our ability to recognize revenue amounts associated therewith; |
• | the interpretation and implementation of state contract performance requirements regarding the achievement of certain quality measures, and our ability to avoid liquidated damages associated therewith; |
• | cyber-attacks or other privacy or data security incidents resulting in an inadvertent unauthorized disclosure of protected health information; |
• | the success of our health plan in Puerto Rico, including the resolution of the Puerto Rico debt crisis, payment of all amounts due under our Medicaid contract, the effect of the newly enacted PROMESA law, and our efforts to better manage the health care costs of our Puerto Rico health plan; |
• | significant budget pressures on state governments and their potential inability to maintain current rates, to implement expected rate increases, or to maintain existing benefit packages or membership eligibility thresholds or criteria, including the resolution of the Illinois budget impasse and continued payment of all amounts due to our Illinois health plan; |
• | the accurate estimation of incurred but not reported or paid medical costs across our health plans; |
• | subsequent adjustments to reported premium revenue based upon subsequent developments or new information, including changes to estimated amounts payable or receivable related to Marketplace risk adjustment/risk transfer, risk corridors, and reinsurance; |
• | efforts by states to recoup previously paid amounts; |
• | the success of our efforts to retain existing government contracts and to obtain new government contracts in connection with state requests for proposals (RFPs) in both existing and new states; |
• | the continuation and renewal of the government contracts of our health plans, Molina Medicaid Solutions, and Pathways, and the terms under which such contracts are renewed; |
• | complications, member confusion, or enrollment backlogs related to the annual renewal of Medicaid coverage; |
• | government audits and reviews, and any fine, enrollment freeze, or monitoring program that may result therefrom; |
• | changes with respect to our provider contracts and the loss of providers; |
• | approval by state regulators of dividends and distributions by our health plan subsidiaries; |
• | changes in funding under our contracts as a result of regulatory changes, programmatic adjustments, or other reforms; |
• | high dollar claims related to catastrophic illness; |
• | the favorable resolution of litigation, arbitration, or administrative proceedings; |
• | the relatively small number of states in which we operate health plans; |
• | the availability of adequate financing on acceptable terms to fund and capitalize our expansion and growth, repay our outstanding indebtedness at maturity and meet our liquidity needs, including the interest expense and other costs associated with such financing; |
• | the failure of a state in which we operate to renew its federal Medicaid waiver; |
• | changes generally affecting the managed care or Medicaid management information systems industries; |
• | increases in government surcharges, taxes, and assessments, including but not limited to the deductibility of certain compensation costs; |
• | newly emergent viruses or widespread epidemics, including the Zika virus, public catastrophes or terrorist attacks, and associated public alarm; |
• | changes in general economic conditions, including unemployment rates; |
• | the sufficiency of our funds on hand to pay the amounts due upon conversion of our outstanding notes; |
• | increasing competition and consolidation in the Medicaid industry; |
Three Months Ended September 30, | Nine Months Ended September 30, | ||||||||||||||
2016 | 2015 | 2016 | 2015 | ||||||||||||
(Dollar amounts in millions, except net income per share) | |||||||||||||||
Revenue: | |||||||||||||||
Premium revenue | $ | 4,191 | $ | 3,377 | $ | 12,215 | $ | 9,652 | |||||||
Service revenue | 133 | 47 | 408 | 146 | |||||||||||
Premium tax revenue | 127 | 99 | 345 | 289 | |||||||||||
Health insurer fee revenue | 85 | 81 | 251 | 203 | |||||||||||
Investment income | 9 | 5 | 25 | 12 | |||||||||||
Other revenue | 1 | 2 | 4 | 5 | |||||||||||
Total revenue | 4,546 | 3,611 | 13,248 | 10,307 | |||||||||||
Operating expenses: | |||||||||||||||
Medical care costs | 3,748 | 3,016 | 10,930 | 8,581 | |||||||||||
Cost of service revenue | 119 | 34 | 362 | 103 | |||||||||||
General and administrative expenses | 343 | 287 | 1,034 | 830 | |||||||||||
Premium tax expenses | 127 | 99 | 345 | 289 | |||||||||||
Health insurer fee expenses | 55 | 36 | 163 | 117 | |||||||||||
Depreciation and amortization | 36 | 26 | 102 | 76 | |||||||||||
Total operating expenses | 4,428 | 3,498 | 12,936 | 9,996 | |||||||||||
Operating income | 118 | 113 | 312 | 311 | |||||||||||
Interest expense | 26 | 15 | 76 | 45 | |||||||||||
Income before income tax expense | 92 | 98 | 236 | 266 | |||||||||||
Income tax expense | 50 | 52 | 137 | 153 | |||||||||||
Net income | $ | 42 | $ | 46 | $ | 99 | $ | 113 | |||||||
Diluted net income per share | $ | 0.76 | $ | 0.77 | $ | 1.77 | $ | 2.07 | |||||||
Diluted weighted average shares outstanding | 56.1 | 60.0 | 56.2 | 54.7 | |||||||||||
Operating Statistics: | |||||||||||||||
Medical care ratio (1) | 89.4 | % | 89.3 | % | 89.5 | % | 88.9 | % | |||||||
General and administrative expense ratio (2) | 7.6 | % | 8.0 | % | 7.8 | % | 8.1 | % | |||||||
Premium tax ratio (1) | 2.9 | % | 2.8 | % | 2.7 | % | 2.9 | % | |||||||
Effective tax rate | 54.0 | % | 52.6 | % | 58.0 | % | 57.3 | % | |||||||
Net profit margin (2) | 0.9 | % | 1.3 | % | 0.7 | % | 1.1 | % |
(1) | Medical care ratio represents medical care costs as a percentage of premium revenue; premium tax ratio represents premium tax expenses as a percentage of premium revenue plus premium tax revenue. |
(2) | Computed as a percentage of total revenue. |
September 30, | December 31, | ||||||
2016 | 2015 | ||||||
(Unaudited) | |||||||
(Amounts in millions, except per-share data) | |||||||
ASSETS | |||||||
Current assets: | |||||||
Cash and cash equivalents | $ | 2,842 | $ | 2,329 | |||
Investments | 1,735 | 1,801 | |||||
Receivables | 1,053 | 597 | |||||
Income taxes refundable | — | 13 | |||||
Prepaid expenses and other current assets | 169 | 192 | |||||
Derivative asset | 314 | 374 | |||||
Total current assets | 6,113 | 5,306 | |||||
Property, equipment, and capitalized software, net | 450 | 393 | |||||
Deferred contract costs | 83 | 81 | |||||
Intangible assets, net | 149 | 122 | |||||
Goodwill | 619 | 519 | |||||
Restricted investments | 116 | 109 | |||||
Deferred income taxes | — | 18 | |||||
Other assets | 40 | 28 | |||||
$ | 7,570 | $ | 6,576 | ||||
LIABILITIES AND STOCKHOLDERS’ EQUITY | |||||||
Current liabilities: | |||||||
Medical claims and benefits payable | $ | 1,871 | $ | 1,685 | |||
Amounts due government agencies | 1,232 | 729 | |||||
Accounts payable and accrued liabilities | 383 | 362 | |||||
Deferred revenue | 380 | 223 | |||||
Income taxes payable | 19 | — | |||||
Current portion of long-term debt | 466 | 449 | |||||
Derivative liability | 314 | 374 | |||||
Total current liabilities | 4,665 | 3,822 | |||||
Senior notes | 971 | 962 | |||||
Lease financing obligations | 198 | 198 | |||||
Deferred income taxes | 6 | — | |||||
Other long-term liabilities | 39 | 37 | |||||
Total liabilities | 5,879 | 5,019 | |||||
Stockholders’ equity: | |||||||
Common stock, $0.001 par value; 150 shares authorized; outstanding: 57 shares at September 30, 2016 and 56 shares at December 31, 2015 | — | — | |||||
Preferred stock, $0.001 par value; 20 shares authorized, no shares issued and outstanding | — | — | |||||
Additional paid-in capital | 831 | 803 | |||||
Accumulated other comprehensive gain (loss) | 3 | (4 | ) | ||||
Retained earnings | 857 | 758 | |||||
Total stockholders’ equity | 1,691 | 1,557 | |||||
$ | 7,570 | $ | 6,576 |
Three Months Ended September 30, | Nine Months Ended September 30, | ||||||||||||||
2016 | 2015 | 2016 | 2015 | ||||||||||||
(Amounts in millions) | |||||||||||||||
Operating activities: | |||||||||||||||
Net income | $ | 42 | $ | 46 | $ | 99 | $ | 113 | |||||||
Adjustments to reconcile net income to net cash provided by operating activities: | |||||||||||||||
Depreciation and amortization | 46 | 31 | 135 | 93 | |||||||||||
Deferred income taxes | (19 | ) | (19 | ) | 20 | (12 | ) | ||||||||
Share-based compensation | 8 | 7 | 24 | 16 | |||||||||||
Amortization of convertible senior notes and lease financing obligations | 8 | 7 | 23 | 22 | |||||||||||
Other, net | 3 | 4 | 14 | 13 | |||||||||||
Changes in operating assets and liabilities: | |||||||||||||||
Receivables | (12 | ) | 12 | (427 | ) | (23 | ) | ||||||||
Prepaid expenses and other assets | 27 | 34 | (116 | ) | (63 | ) | |||||||||
Medical claims and benefits payable | 86 | 67 | 168 | 359 | |||||||||||
Amounts due government agencies | (6 | ) | 155 | 503 | 453 | ||||||||||
Accounts payable and accrued liabilities | (146 | ) | (124 | ) | 1 | 34 | |||||||||
Deferred revenue | 276 | 9 | 157 | (129 | ) | ||||||||||
Income taxes | 42 | 29 | 32 | 30 | |||||||||||
Net cash provided by operating activities | 355 | 258 | 633 | 906 | |||||||||||
Investing activities: | |||||||||||||||
Purchases of investments | (470 | ) | (318 | ) | (1,444 | ) | (1,311 | ) | |||||||
Proceeds from sales and maturities of investments | 700 | 322 | 1,512 | 863 | |||||||||||
Purchases of property, equipment, and capitalized software | (41 | ) | (35 | ) | (143 | ) | (101 | ) | |||||||
Change in restricted investments | (1 | ) | 9 | 4 | (5 | ) | |||||||||
Net cash paid in business combinations | (40 | ) | (69 | ) | (48 | ) | (77 | ) | |||||||
Other, net | (6 | ) | (17 | ) | (12 | ) | (34 | ) | |||||||
Net cash provided by (used in) investing activities | 142 | (108 | ) | (131 | ) | (665 | ) | ||||||||
Financing activities: | |||||||||||||||
Proceeds from common stock offering, net of issuance costs | — | — | — | 373 | |||||||||||
Proceeds from employee stock plans | — | — | 10 | 8 | |||||||||||
Other, net | — | — | 1 | 3 | |||||||||||
Net cash provided by financing activities | — | — | 11 | 384 | |||||||||||
Net increase in cash and cash equivalents | 497 | 150 | 513 | 625 | |||||||||||
Cash and cash equivalents at beginning of period | 2,345 | 2,014 | 2,329 | 1,539 | |||||||||||
Cash and cash equivalents at end of period | $ | 2,842 | $ | 2,164 | $ | 2,842 | $ | 2,164 |
Three Months Ended September 30, | Nine Months Ended September 30, | ||||||||||||||
2016 | 2015 | 2016 | 2015 | ||||||||||||
(Amounts in millions) | |||||||||||||||
Net income | $ | 42 | $ | 46 | $ | 99 | $ | 113 | |||||||
Adjustments: | |||||||||||||||
Depreciation, and amortization of intangible assets and capitalized software | 42 | 29 | 118 | 87 | |||||||||||
Interest expense | 26 | 15 | 76 | 45 | |||||||||||
Income tax expense | 50 | 52 | 137 | 153 | |||||||||||
EBITDA | $ | 160 | $ | 142 | $ | 430 | $ | 398 |
Three Months Ended September 30, | Nine Months Ended September 30, | ||||||||||||||||||||||||||||||
2016 | 2015 | 2016 | 2015 | ||||||||||||||||||||||||||||
(In millions, except per diluted share amounts) | |||||||||||||||||||||||||||||||
Amount | Per share | Amount | Per share | Amount | Per share | Amount | Per share | ||||||||||||||||||||||||
Net income | $ | 42 | $ | 0.76 | $ | 46 | $ | 0.77 | $ | 99 | $ | 1.77 | $ | 113 | $ | 2.07 | |||||||||||||||
Adjustment, net of tax: | |||||||||||||||||||||||||||||||
Amortization of intangible assets | 5 | 0.09 | 2 | 0.04 | 15 | 0.26 | 8 | 0.15 | |||||||||||||||||||||||
Adjusted net income | $ | 47 | $ | 0.85 | $ | 48 | $ | 0.81 | $ | 114 | $ | 2.03 | $ | 121 | $ | 2.22 |
September 30, | December 31, | September 30, | ||||||
2016 | 2015 | 2015 | ||||||
Ending Membership by Health Plan: | ||||||||
California | 683,000 | 620,000 | 611,000 | |||||
Florida | 563,000 | 440,000 | 349,000 | |||||
Illinois | 195,000 | 98,000 | 101,000 | |||||
Michigan | 387,000 | 328,000 | 340,000 | |||||
New Mexico | 253,000 | 231,000 | 231,000 | |||||
New York (1) | 37,000 | — | — | |||||
Ohio | 339,000 | 327,000 | 344,000 | |||||
Puerto Rico | 331,000 | 348,000 | 356,000 | |||||
South Carolina | 109,000 | 99,000 | 102,000 | |||||
Texas | 352,000 | 260,000 | 263,000 | |||||
Utah | 150,000 | 102,000 | 102,000 | |||||
Washington | 716,000 | 582,000 | 568,000 | |||||
Wisconsin | 131,000 | 98,000 | 103,000 | |||||
4,246,000 | 3,533,000 | 3,470,000 | ||||||
Ending Membership by Program: | ||||||||
Temporary Assistance for Needy Families (TANF) and Children's Health Insurance Program (CHIP) | 2,529,000 | 2,312,000 | 2,249,000 | |||||
Medicaid Expansion | 658,000 | 557,000 | 540,000 | |||||
Marketplace | 568,000 | 205,000 | 226,000 | |||||
Aged, Blind or Disabled (ABD) | 395,000 | 366,000 | 359,000 | |||||
Medicare-Medicaid Plan (MMP) - Integrated | 51,000 | 51,000 | 56,000 | |||||
Medicare Special Needs Plans | 45,000 | 42,000 | 40,000 | |||||
4,246,000 | 3,533,000 | 3,470,000 |
(1) | The New York health plan was acquired on August 1, 2016. |
Three Months Ended September 30, 2016 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
California | 2.1 | $ | 612 | $ | 298.05 | $ | 523 | $ | 254.11 | 85.3 | % | $ | 89 | ||||||||||||
Florida | 1.6 | 494 | 297.24 | 462 | 277.79 | 93.5 | 32 | ||||||||||||||||||
Illinois | 0.6 | 163 | 275.26 | 145 | 244.86 | 89.0 | 18 | ||||||||||||||||||
Michigan | 1.2 | 387 | 334.25 | 337 | 290.16 | 86.8 | 50 | ||||||||||||||||||
New Mexico | 0.8 | 338 | 440.12 | 304 | 396.35 | 90.1 | 34 | ||||||||||||||||||
New York(3) | 0.1 | 32 | 427.40 | 30 | 403.71 | 94.5 | 2 | ||||||||||||||||||
Ohio | 1.0 | 501 | 491.51 | 424 | 415.87 | 84.6 | 77 | ||||||||||||||||||
Puerto Rico | 1.0 | 184 | 183.46 | 167 | 167.44 | 91.3 | 17 | ||||||||||||||||||
South Carolina | 0.3 | 102 | 312.28 | 94 | 285.97 | 91.6 | 8 | ||||||||||||||||||
Texas | 1.1 | 597 | 559.98 | 525 | 493.07 | 88.1 | 72 | ||||||||||||||||||
Utah | 0.4 | 106 | 236.31 | 104 | 230.53 | 97.6 | 2 | ||||||||||||||||||
Washington | 2.1 | 569 | 265.48 | 521 | 243.49 | 91.7 | 48 | ||||||||||||||||||
Wisconsin | 0.4 | 103 | 262.32 | 90 | 231.86 | 88.4 | 13 | ||||||||||||||||||
Other(4) | — | 3 | — | 22 | — | — | (19 | ) | |||||||||||||||||
12.7 | $ | 4,191 | $ | 329.88 | $ | 3,748 | $ | 295.01 | 89.4 | % | $ | 443 | |||||||||||||
Three Months Ended September 30, 2015 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
California | 1.9 | $ | 524 | $ | 288.45 | $ | 438 | $ | 241.09 | 83.6 | % | $ | 86 | ||||||||||||
Florida | 0.9 | 300 | 299.33 | 265 | 264.39 | 88.3 | 35 | ||||||||||||||||||
Illinois | 0.3 | 106 | 347.34 | 100 | 327.61 | 94.3 | 6 | ||||||||||||||||||
Michigan | 0.9 | 281 | 330.00 | 236 | 276.61 | 83.8 | 45 | ||||||||||||||||||
New Mexico | 0.7 | 297 | 421.76 | 275 | 390.26 | 92.5 | 22 | ||||||||||||||||||
New York(3) | — | — | — | — | — | — | — | ||||||||||||||||||
Ohio | 1.0 | 510 | 498.36 | 436 | 425.98 | 85.5 | 74 | ||||||||||||||||||
Puerto Rico | 1.0 | 181 | 170.91 | 162 | 152.69 | 89.3 | 19 | ||||||||||||||||||
South Carolina | 0.3 | 86 | 264.37 | 68 | 211.76 | 80.1 | 18 | ||||||||||||||||||
Texas | 0.8 | 524 | 661.69 | 493 | 622.84 | 94.1 | 31 | ||||||||||||||||||
Utah | 0.3 | 85 | 276.72 | 77 | 250.50 | 90.5 | 8 | ||||||||||||||||||
Washington | 1.7 | 400 | 238.03 | 371 | 221.14 | 92.9 | 29 | ||||||||||||||||||
Wisconsin | 0.3 | 71 | 232.32 | 57 | 184.94 | 79.6 | 14 | ||||||||||||||||||
Other(4) | — | 12 | — | 38 | — | — | (26 | ) | |||||||||||||||||
10.1 | $ | 3,377 | $ | 332.05 | $ | 3,016 | $ | 296.49 | 89.3 | % | $ | 361 |
(1) | A member month is defined as the aggregate of each month’s ending membership for the period presented. |
(2) | The MCR represents medical costs as a percentage of premium revenue. |
(3) | The New York health plan was acquired on August 1, 2016. |
(4) | “Other” medical care costs include primarily medically related administrative costs at the parent company, and direct delivery costs. |
Nine Months Ended September 30, 2016 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
California | 6.1 | $ | 1,707 | $ | 280.21 | $ | 1,485 | $ | 243.64 | 86.9 | % | $ | 222 | ||||||||||||
Florida | 5.0 | 1,447 | 288.74 | 1,301 | 259.60 | 89.9 | 146 | ||||||||||||||||||
Illinois | 1.8 | 466 | 266.11 | 414 | 236.39 | 88.8 | 52 | ||||||||||||||||||
Michigan | 3.6 | 1,143 | 322.08 | 1,018 | 286.77 | 89.0 | 125 | ||||||||||||||||||
New Mexico | 2.3 | 1,016 | 447.07 | 905 | 398.22 | 89.1 | 111 | ||||||||||||||||||
New York(3) | 0.1 | 32 | 427.40 | 30 | 403.71 | 94.5 | 2 | ||||||||||||||||||
Ohio | 3.0 | 1,472 | 484.82 | 1,306 | 430.14 | 88.7 | 166 | ||||||||||||||||||
Puerto Rico | 3.0 | 535 | 176.44 | 516 | 170.46 | 96.6 | 19 | ||||||||||||||||||
South Carolina | 0.9 | 273 | 288.93 | 232 | 245.13 | 84.8 | 41 | ||||||||||||||||||
Texas | 3.3 | 1,852 | 570.65 | 1,599 | 492.79 | 86.4 | 253 | ||||||||||||||||||
Utah | 1.3 | 330 | 246.78 | 312 | 233.14 | 94.5 | 18 | ||||||||||||||||||
Washington | 6.2 | 1,634 | 261.91 | 1,479 | 237.15 | 90.5 | 155 | ||||||||||||||||||
Wisconsin | 1.2 | 299 | 252.45 | 278 | 235.25 | 93.2 | 21 | ||||||||||||||||||
Other(4) | — | 9 | — | 55 | — | — | (46 | ) | |||||||||||||||||
37.8 | $ | 12,215 | $ | 323.44 | $ | 10,930 | $ | 289.41 | 89.5 | % | $ | 1,285 | |||||||||||||
Nine Months Ended September 30, 2015 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
California | 5.3 | $ | 1,538 | $ | 292.64 | $ | 1,349 | $ | 256.71 | 87.7 | % | $ | 189 | ||||||||||||
Florida | 2.9 | 868 | 294.05 | 763 | 258.49 | 87.9 | 105 | ||||||||||||||||||
Illinois | 0.9 | 312 | 342.27 | 288 | 315.68 | 92.2 | 24 | ||||||||||||||||||
Michigan | 2.4 | 738 | 310.01 | 621 | 260.53 | 84.0 | 117 | ||||||||||||||||||
New Mexico | 2.1 | 933 | 448.75 | 843 | 405.60 | 90.4 | 90 | ||||||||||||||||||
New York(3) | — | — | — | — | — | — | — | ||||||||||||||||||
Ohio | 3.1 | 1,534 | 498.76 | 1,281 | 416.69 | 83.5 | 253 | ||||||||||||||||||
Puerto Rico | 2.1 | 375 | 175.17 | 346 | 161.60 | 92.3 | 29 | ||||||||||||||||||
South Carolina | 1.0 | 270 | 269.11 | 209 | 208.45 | 77.5 | 61 | ||||||||||||||||||
Texas | 2.4 | 1,418 | 597.53 | 1,313 | 553.35 | 92.6 | 105 | ||||||||||||||||||
Utah | 0.8 | 242 | 284.83 | 223 | 262.14 | 92.0 | 19 | ||||||||||||||||||
Washington | 4.9 | 1,186 | 242.75 | 1,094 | 223.99 | 92.3 | 92 | ||||||||||||||||||
Wisconsin | 0.9 | 206 | 221.97 | 162 | 173.99 | 78.4 | 44 | ||||||||||||||||||
Other(4) | — | 32 | — | 89 | — | — | (57 | ) | |||||||||||||||||
28.8 | $ | 9,652 | $ | 334.74 | $ | 8,581 | $ | 297.58 | 88.9 | % | $ | 1,071 |
(1) | A member month is defined as the aggregate of each month’s ending membership for the period presented. |
(2) | The MCR represents medical costs as a percentage of premium revenue. |
(3) | The New York health plan was acquired on August 1, 2016. |
(4) | “Other” medical care costs include primarily medically related administrative costs at the parent company, and direct delivery costs. |
Three Months Ended September 30, 2016 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
TANF and CHIP | 7.6 | $ | 1,373 | $ | 180.74 | $ | 1,246 | $ | 164.04 | 90.8 | % | $ | 127 | ||||||||||||
Medicaid Expansion | 2.0 | 763 | 386.98 | 642 | 325.68 | 84.2 | 121 | ||||||||||||||||||
Marketplace | 1.7 | 399 | 238.86 | 352 | 210.38 | 88.1 | 47 | ||||||||||||||||||
ABD | 1.1 | 1,186 | 1,008.28 | 1,094 | 929.93 | 92.2 | 92 | ||||||||||||||||||
MMP | 0.2 | 334 | 2,165.26 | 280 | 1,818.75 | 84.0 | 54 | ||||||||||||||||||
Medicare | 0.1 | 136 | 1,019.19 | 134 | 1,003.85 | 98.5 | 2 | ||||||||||||||||||
12.7 | $ | 4,191 | $ | 329.88 | $ | 3,748 | $ | 295.01 | 89.4 | % | $ | 443 |
Three Months Ended September 30, 2015 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
TANF and CHIP | 6.6 | $ | 1,139 | $ | 171.16 | $ | 1,070 | $ | 160.85 | 94.0 | % | $ | 69 | ||||||||||||
Medicaid Expansion | 1.5 | 565 | 366.80 | 458 | 297.16 | 81.0 | 107 | ||||||||||||||||||
Marketplace | 0.6 | 170 | 262.74 | 124 | 192.21 | 73.2 | 46 | ||||||||||||||||||
ABD | 1.1 | 1,070 | 1,017.68 | 979 | 931.11 | 91.5 | 91 | ||||||||||||||||||
MMP | 0.2 | 310 | 1,975.10 | 271 | 1,718.13 | 87.0 | 39 | ||||||||||||||||||
Medicare | 0.1 | 123 | 1,002.50 | 114 | 930.43 | 92.8 | 9 | ||||||||||||||||||
10.1 | $ | 3,377 | $ | 332.05 | $ | 3,016 | $ | 296.49 | 89.3 | % | $ | 361 |
Nine Months Ended September 30, 2016 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
TANF and CHIP | 22.5 | $ | 3,999 | $ | 177.60 | $ | 3,646 | $ | 161.93 | 91.2 | % | $ | 353 | ||||||||||||
Medicaid Expansion | 5.8 | 2,184 | 376.98 | 1,850 | 319.38 | 84.7 | 334 | ||||||||||||||||||
Marketplace | 5.1 | 1,181 | 231.69 | 1,009 | 197.77 | 85.4 | 172 | ||||||||||||||||||
ABD | 3.5 | 3,466 | 987.20 | 3,173 | 903.85 | 91.6 | 293 | ||||||||||||||||||
MMP | 0.5 | 989 | 2,160.14 | 867 | 1,894.38 | 87.7 | 122 | ||||||||||||||||||
Medicare | 0.4 | 396 | 1,015.14 | 385 | 986.40 | 97.2 | 11 | ||||||||||||||||||
37.8 | $ | 12,215 | $ | 323.44 | $ | 10,930 | $ | 289.41 | 89.5 | % | $ | 1,285 |
Nine Months Ended September 30, 2015 | |||||||||||||||||||||||||
Member Months(1) | Premium Revenue | Medical Care Costs | MCR(2) | Medical Margin | |||||||||||||||||||||
Total | PMPM | Total | PMPM | ||||||||||||||||||||||
TANF and CHIP | 18.6 | $ | 3,280 | $ | 175.52 | $ | 3,030 | $ | 162.16 | 92.4 | % | $ | 250 | ||||||||||||
Medicaid Expansion | 4.2 | 1,654 | 393.71 | 1,325 | 315.33 | 80.1 | 329 | ||||||||||||||||||
Marketplace | 2.0 | 525 | 259.97 | 370 | 183.33 | 70.5 | 155 | ||||||||||||||||||
ABD | 3.2 | 3,063 | 965.91 | 2,789 | 879.27 | 91.0 | 274 | ||||||||||||||||||
MMP | 0.4 | 733 | 1,981.40 | 684 | 1,847.03 | 93.2 | 49 | ||||||||||||||||||
Medicare | 0.4 | 397 | 1,026.00 | 383 | 991.53 | 96.6 | 14 | ||||||||||||||||||
28.8 | $ | 9,652 | $ | 334.74 | $ | 8,581 | $ | 297.58 | 88.9 | % | $ | 1,071 |
(1) | A member month is defined as the aggregate of each month’s ending membership for the period presented. |
(2) | The MCR represents medical costs as a percentage of premium revenue. |
Three Months Ended September 30, | |||||||||||||||||||||
2016 | 2015 | ||||||||||||||||||||
Amount | PMPM | % of Total | Amount | PMPM | % of Total | ||||||||||||||||
Fee for service | $ | 2,799 | $ | 220.29 | 74.7 | % | $ | 2,224 | $ | 218.69 | 73.8 | % | |||||||||
Pharmacy | 567 | 44.65 | 15.1 | 418 | 41.07 | 13.9 | |||||||||||||||
Capitation | 302 | 23.83 | 8.1 | 260 | 25.57 | 8.6 | |||||||||||||||
Direct delivery | 21 | 1.66 | 0.5 | 31 | 2.97 | 1.0 | |||||||||||||||
Other | 59 | 4.58 | 1.6 | 83 | 8.19 | 2.7 | |||||||||||||||
$ | 3,748 | $ | 295.01 | 100.0 | % | $ | 3,016 | $ | 296.49 | 100.0 | % |
Nine Months Ended September 30, | |||||||||||||||||||||
2016 | 2015 | ||||||||||||||||||||
Amount | PMPM | % of Total | Amount | PMPM | % of Total | ||||||||||||||||
Fee for service | $ | 8,156 | $ | 215.96 | 74.6 | % | $ | 6,275 | $ | 217.63 | 73.1 | % | |||||||||
Pharmacy | 1,621 | 42.93 | 14.8 | 1,161 | 40.26 | 13.5 | |||||||||||||||
Capitation | 901 | 23.86 | 8.3 | 725 | 25.13 | 8.5 | |||||||||||||||
Direct delivery | 55 | 1.46 | 0.5 | 85 | 2.94 | 1.0 | |||||||||||||||
Other | 197 | 5.20 | 1.8 | 335 | 11.62 | 3.9 | |||||||||||||||
$ | 10,930 | $ | 289.41 | 100.0 | % | $ | 8,581 | $ | 297.58 | 100.0 | % |
September 30, | December 31, | ||||||
2016 | 2015 | ||||||
Fee-for-service claims incurred but not paid (IBNP) | $ | 1,333 | $ | 1,191 | |||
Pharmacy payable | 114 | 88 | |||||
Capitation payable | 27 | 140 | |||||
Other (1) | 397 | 266 | |||||
$ | 1,871 | $ | 1,685 |
(1) | “Other” medical claims and benefits payable include amounts payable to certain providers for which we act as an intermediary on behalf of various state agencies without assuming financial risk. Such receipts and payments do not impact our consolidated statements of income. As of September 30, 2016 and December 31, 2015, we had recorded non-risk provider payables of approximately $237 million and $167 million, respectively. |
Year Ended | |||||||||||
Nine Months Ended September 30, | December 31, | ||||||||||
2016 | 2015 | 2015 | |||||||||
Medical claims and benefits payable, beginning balance | $ | 1,685 | $ | 1,201 | $ | 1,201 | |||||
Components of medical care costs related to: | |||||||||||
Current period | 11,120 | 8,724 | 11,935 | ||||||||
Prior period | (190 | ) | (143 | ) | (141 | ) | |||||
Total medical care costs | 10,930 | 8,581 | 11,794 | ||||||||
Change in non-risk provider payables | 70 | 42 | 48 | ||||||||
Payments for medical care costs related to: | |||||||||||
Current period | 9,536 | 7,372 | 10,448 | ||||||||
Prior period | 1,278 | 892 | 910 | ||||||||
Total paid | 10,814 | 8,264 | 11,358 | ||||||||
Medical claims and benefits payable, ending balance | $ | 1,871 | $ | 1,560 | $ | 1,685 | |||||
Benefit from prior period as a percentage of: | |||||||||||
Balance at beginning of period | 11.3 | % | 11.9 | % | 11.8 | % | |||||
Premium revenue, trailing twelve months | 1.2 | % | 1.2 | % | 1.1 | % | |||||
Medical care costs, trailing twelve months | 1.3 | % | 1.3 | % | 1.2 | % | |||||
Fee-For-Service Claims Data: | |||||||||||
Days in claims payable, fee for service | 47 | 49 | 48 | ||||||||
Number of members at end of period | 4,246,000 | 3,470,000 | 3,533,000 | ||||||||
Number of claims in inventory at end of period | 580,200 | 408,100 | 380,800 | ||||||||
Billed charges of claims in inventory at end of period | $ | 1,346 | $ | 908 | $ | 816 | |||||
Claims in inventory per member at end of period | 0.14 | 0.12 | 0.11 | ||||||||
Billed charges of claims in inventory per member at end of period | $ | 316.89 | $ | 261.73 | $ | 230.91 | |||||
Number of claims received during the period | 39,683,800 | 29,084,100 | 40,173,300 | ||||||||
Billed charges of claims received during the period | $ | 48,017 | $ | 33,517 | $ | 46,211 |