Centene Corporation (CNC) Earnings Call Transcript & Summary

Good morning, everyone. I'm Jennifer Gilligan, Senior Vice President of Finance and Investor Relations. Welcome to Centene's December 2022 Investor Day. We're broadcasting live from the New York Stock Exchange, and I want to thank the folks in the room as well as those on the webcast for joining us. A few practical points to start us off. Today's press release and slide presentation, as well as management bios, are available on the Investor Relations page of centene.com. For those joining virtually, materials are also available within the webcast player. Finally, please mark your calendar for our fourth quarter 2022 earnings call scheduled for Tuesday, February 7. Here is a part of the program that will surely warm the holiday hearts of attorneys everywhere. Please note that various remarks we make today regarding future expectations, plans and prospects constitute forward-looking statements under U.S. Securities Law, actual results may differ materially from those indicated by these statements as a result of various important factors and risks included -- including those discussed in the slide you see in front of you, as well as risk factors contained in our most recent annual report and other SEC filings. Centene disclaims any obligation to update this forward-looking financial information in the future. Additionally, during this presentation, we will be discussing certain non-GAAP financial measures. A reconciliation of these measures with the most directly comparable GAAP measures can be found in today's slide presentation, which is available on our website at centene.com. On Page 3 of our slide presentation, you'll find our agenda for today. We have a full program this morning that will open with a strategic overview from our CEO, Sarah London. She'll pass the floor to Ken Fasola for an update on the core businesses. Following Ken, we will host 2 panel discussions. Our first panel, led by Jim Murray, is centered on our efforts to focus and fortify Centene's platform for growth, and features key members of our team leading high priority value-creation initiatives. Our second panel, hosted by Ken Fasola and Brent Layton, is designed as a deeper dive into the powerful growth opportunities that our core business line leaders C for Centene in 2025 and beyond. Jon Dinesman will bring us back from a short break, providing comments around the current health care and political landscape, and Drew Asher will round out our prepared remarks with a discussion around our financial outlook. We will close the morning with a leadership Q&A session. For Q&A, we will predominantly take questions from -- in the room, but we will also look to answer some questions from the web. [Operator Instructions]. Finally, we'd like to thank everyone for the donations to the children's clothing organization Like drive. We are humbled to partner with organizations like Literacy Inc. and many like them nationwide, providing vital services to economically challenged Americans. If you've never heard of Literacy Inc, please check out their website lincnyc.org to hear more about the incredible work they do every single day to support local communities and our members right here in New York. A big thanks to Tom Halloran, our New York Health Plan President, and his team for facilitating this opportunity to connect with investors with our community outreach. And with that, I'll pass the floor to Sarah.

Good morning, and welcome. It's good to see everyone. We're very excited to be back in New York City in person, and we're grateful you've joined us for Investor Day in this incredible free venue. My job this morning is to walk you through the pillars of Centene's long-term strategy. And to outline the specific reasons we believe our company is uniquely positioned to win within each of our chosen markets. Over the past 20 years, Centene has become the industry leader in government-sponsored health care with an established expertise in lower income and medically complex populations. Our unmatched record of organic growth and strategic acquisitions, has given Centene the size and scale and the privilege of providing local high-quality and affordable health care to more than 26 million Americans. Today, we are the leading Medicaid health insurer in the country, serving more than 15 million Medicaid recipients in 30 states. We're the largest marketplace carrier, serving more than 2.1 million members across 28 states, and we've grown to serve close to 1.5 million Medicare members across 36 states, with the highest concentration of lower-income, medically complex members. But it's no secret, our extraordinary growth came at a cost. It brought additional levels of complexity of systems and businesses that required care and feeding of their own and drew resources from the company's purest focus on its 3 core product lines. That's why in June of last year, we launched our value creation plan, and this management team began the hard work necessary to streamline Centene's operating model to materially improve gross margins and to deploy capital in a more disciplined manner than ever before, all with the goal of building the foundation for Centene's success over the next decade. Jim Murray will share an update on value creation shortly, but here's the punch line: We made promises and we kept them. We had grew profitably. We achieved our operational milestones. We divested and continue to divest non-core assets, and we deployed capital in a disciplined and efficient way against our value creation framework. We did all of this while managing through tremendous change, and still showing up in the way only Centene does for our communities, in Buffalo, in Uvalde, Fort Myers, Eastern Kentucky and many more. Why is this important? Because focusing on our core business and prioritizing value creation are not just short-term ideas. They are key pillars of our long-term strategy. The work we do in 2022, '23 and '24 will not only align with but naturally fuel our next phase of innovation and growth. We said those exact words a year ago, and we believe them even more strongly today. The first thing I'd ask you to take away from today is this. Centene has a unique and powerful platform, and we are working hard to fortify its foundation through our value creation efforts. Building on that platform, we intend to drive sustainable, profitable growth and long-term value to our members and to our shareholders. Here's how. We will stay laser-focused on Medicaid, Marketplace and Medicare, capitalizing on the significant expansion opportunities we see in each market. We will grow by tapping into our inherent and differentiating strengths by being local and easy to work with, by building strategic partnerships that deliver differentiated outcomes, and by leading the industry in data-driven innovation. We will evolve as the market evolves and position Centene for a right to win across adjacent and emerging markets. We will bring together industry-leading, mission-driven talent to guide this organization through the transformation of our business. And finally, we will deliver 12% to 15% adjusted EPS growth over the long term. Now that you have the headlines, let's dig into the story. We are focused on our core business because our core business is exactly the right starting point for long-term growth. Spending in government programs will be a key driver of overall health care spending for the foreseeable future, growing 55% over the next decade, which means Centene stands as an established leader in the most attractive segment of managed care. On top of this overall market growth, each of our 3 markets contains untapped opportunity for expansion. The Medicaid market is expected to grow from $700 billion to $1.1 trillion by 2029. Within this market, there are 20 states, representing more than $135 billion in Medicaid spend that have not yet adopted managed care or where Centene does not yet operate. Having built 25 of our 31 health plans from scratch, Centene's business development teams are expert at positioning Centene to win new state opportunities. Case in point, Delaware. By investing time on the ground in the community, we stood out in the RFP process earlier this year, and earned the right to build our 31st health plan in the Diamond State. These kinds of opportunities are second nature to Centene, and we intend to aggressively pursue them over the coming years. Equally compelling is the opportunity for growth serving complex populations. The 20% of beneficiaries that are not currently in managed Medicaid are overwhelmingly complex and represents 40% of total Medicaid spending. Today, these programs, LTSS, ABD, SSI, Foster Care and others represent a larger share of Centene's Medicaid portfolio than they do for any other payer in the country. We consistently deliver high-quality outcomes for these members, thanks to our comprehensive approach to program design. As states increasingly look to a managed model for these populations, we believe Centene will be seen as a must-have partner. Going forward, we will generate new Medicaid wins and work to maintain our current book of business. We are confident that our pipeline built bottom-up, state by state and based on our deep local knowledge, strongly supports the case for 6% to 7% Medicaid revenue growth over the long term. We are the Medicaid market leader, and we intend to maintain our #1 position for years to come. Turning to marketplace. Over the last decade, the exchange market has grown to $84 billion annually, and is projected to reach $170 billion by the end of the decade. Here, Centene is an N of one, one of the first to enter this market and the only major player never to leave. We have been successful from the beginning because we understood the important interplay between Medicaid and Marketplace, and constructed our Marketplace footprint with Medicaid compatibility in mind, allowing us to create coverage continuity for members who transition across these lines of business regularly. And our commitment to this market has allowed us to build differentiating brand recognition and best-in-class distribution partnerships. Going forward, we see Marketplace as an exciting growth opportunity, thanks to its increasing role as a durable, affordable extension of the health safety net. Short term, Marketplace will serve as a valuable coverage option for members who are no longer eligible for Medicaid post redeterminations. Medium term, Marketplace can expand its role as an alternative to Medicaid, and with 89% of our Marketplace membership receiving federal subsidies, members will be able to count on both continuity of coverage and better outcomes in the future. And long term, we believe that consumer demand for affordability, convenience and customized benefit options will support the individual marketplace as a robust alternative to commercial group insurance. It is an opportunity for which Centene, the nation's marketplace leader will be uniquely positioned. With an achievable plan for mid to high single-digit revenue growth and a long-term pre-tax margin profile of 5% to 7.5%, Marketplace has a strong outlook, and we are well positioned to capture our fair share of a growing market while delivering long-term value to our shareholders. Finally, Medicare. As with our other products, there is still plenty of room to grow in Medicare. Medicare spending is expected to increase from $865 billion last year to $1.5 trillion by 2030, and more than 50% of Medicare eligible members have not yet enrolled in a Medicare Advantage product. During this value creation phase, Centene's Medicare team is focused on margin improvement and fortifying our Medicare operations, including STAR's performance, which you will hear more about later in the program. This is the lens through which you should evaluate our Medicare performance in 2023 and 2024. Our goal is to have strong fundamentals in place as we come out of 2024 and shift back into growth mode. Looking to the back half of the decade, we see a clear opportunity for Centene to establish a differentiated position within the Medicare market and drive consistent profitable growth over the long term. Our expertise serving low-income, medically complex populations aligns perfectly with a market where nearly 41% of Medicare-eligible seniors live below 200% of the federal poverty line. And where the number of seniors living with multiple chronic conditions is expected to double over the next decade. This expertise will also enable us to become the market leader in serving dual-eligible populations. With Medicaid market presence and performance increasingly a prerequisite to serving duals programs and with 80% of our dual eligible members currently unaligned, Centene is ideally positioned to leverage our Medicaid chassis and further integrate care in dual-eligible special needs plans. In other words, Medicare market trends are aligned with Centene's strengths, and we should be able to grow at or above industry levels and be a leader in this space. With an addressable market growing to $2.8 trillion by 2030 across our 3 core lines of business, Centene has plenty of room to grow, and we are starting our journey from a position of strength. As we look to capture the significant growth opportunities in our markets and retain our foundational business, we will need to leverage the strengths we bring to the market today, innovate to solve for the challenges of the future, and ultimately, create long-lasting advantage. Centene's definition of competitive advantage is simple. These are the elements of our business that give us the right to win and enable us to best serve our members. So on this long-term journey, how will Centene win? First, we will remain local. One of Centene's greatest strength is our local approach. As we look to evolve our products and meet our members' needs, Centene's ability to inform everything from benefit design to pricing, to groundbreaking community partnerships is hands down better than our competitors because we are on the ground in the community, living side by side with our members. Let me make this real for a moment. Last month, I visited our Home State Health Plan in Missouri. I spent time with team members from our Sole Source Foster Care program and asked them a very simple question, how is it going? One of these colleagues replied, Centene's program is better than anything we've ever had before. I paused at the turn of phrase, and she went on to explain that she herself was a foster mom of a child with behavioral needs. Other team members noted from personal experience as she spoke. So get this: Half of the Home State team members around the table that day were themselves foster parents. What's my point? We have team members across the country who show up every day to make sure that our programs are good enough for their family members. If that doesn't strike you as a competitive advantage, I'm not sure what will. And while we are transforming our operating model to take advantage of our national scale, our commitment to local, to the communities we serve, will never change. Quite the opposite. We plan to fortify our local focus because of the untapped potential it can bring to members, providers and government partners. Going forward, health care is only becoming more local, and local is what Centene does and will continue to do best. Second, we will be easy to work with. You've already heard a lot about this over the last year as a core tenet of our value creation program because this is where we are building a core competency and not just scaling existing strengths. Centene is investing to become easy to work with. This requires modernizing our systems and processes to reduce complexity and deliver the basics really well. It means designing seamless experiences for our members and delivering actionable data for our provider partners, and easy means we can focus our discussions with state and federal partners on innovation and not administration. We have some work to do here, but Centene's mission-driven workforce is motivated to create unmatched member, provider and employee experiences and deliver outsized impact as a result. Third, we will partner to deliver value. Centene is really good at building partnerships. This has been a bedrock of our business development performance over the years and the key to our success across both Medicaid and Marketplace. Going forward, we see incredible power in expanding this partnership discipline across the enterprise. Rather than owning enabling capabilities, we will be the best integrators and disintegrators of technology and innovation in the industry, and by doing so, Centene will become the low-cost platform for market-leading health outcomes. This starts with our value-based provider strategy. As you'll hear later in the program, alignment with high-performing value-based providers will be a significant lever for improved performance and outcomes across our business lines, with particular impact in Medicaid and Medicare in the short term. Ultimately, our goal is to move as many members as we can into value-based contracts by building the strongest possible provider networks in each community. This means being able to select the best performing providers, not just ones we own, to serve our members. Instead of ownership, we will focus on enablement, bringing our strengths in data and community insights to bear and becoming a preferred provider partner. The benefit of this strategy is that it works everywhere across provider types, across business lines, across geographies, allowing Centene to seamlessly work with innovative Medicare Advantage providers as with crucial neighborhood FQHCs serving our Medicaid members and allowing us to remain focused on our core operating model. Finally, we will innovate. It is rare for an organization to reach this size and scale and remember how to innovate, but Centene does. It comes from years of frontline, mission-driven problem solving that still happens every day across 30 states. The opportunity ahead is to harness the innovation that is already happening today in Centene markets across the country and scale it. I could give countless examples, but the key to all of them is the same: Data. In health care, data, not technology is the true source of innovation and transformation, and no one has data like ours. A decade ago, I was part of a team that developed one of the early predictive models using data from electronic health records. Our most powerful model was able to predict asthma-related hospitalizations in children with more than 90% accuracy. Interestingly, when we unpack the underlying algorithm, we found the power of the model had nothing to do with clinical factors. The single, most powerful predictive variable for an uncontrollable pediatric asthma attack was ZIP code. Where our members live drives more than 80% of their health outcomes. Local matters most, and Centene is uniquely positioned to take our rich, local data amassed over decades and build an engine for scalable innovation. Our data will allow us to curate best-in-class networks of community partners and community resources the same way we build high-performing provider networks. Data will allow us to identify low-cost, sustainable interventions that actually work in our populations so that we can invest to scale them and consistently deliver proven impact in our programs. And our data will guide high-impact investments into the community, ensuring the health care resources in those communities match the comprehensive needs and reflect the diversity of our members. In this way, our data will enable us to transform the health, not just the health care of our communities, long term, and deliver equal value to members and shareholders. The picture that I hope is emerging is this: Once again, Centene has a unique and powerful platform, and we are working to fortify its foundation during this value creation phase. We see strong, long-term growth grounded in our core product lines. At the same time, we are keeping our eye on, and in some cases, working to shape where the market is moving. And our strategy absolutely leaves room to explore logical additions and market adjacencies. We will continue to actively pursue M&A, which we will complement with an R&D road map, but we have a high bar. Regardless of whether we build or buy, new opportunities must clearly align with our core businesses or amplify our core competencies. Finally, we are taking Centene's strengths and making them industrial strength, while simultaneously investing to become easy to work with across an enhanced network of partnerships. This is a winning combination, and is Centene's long-term strategy to remain an innovative market leader. Before I close, I want to take a minute on one more important piece of our strategy, our team. Earlier this week, we announced a number of exciting leadership changes, including bringing new talent into the organization and aligning our most senior leaders with the needs of our business going forward. With Ken bringing proven disciplined leadership across our lines of business, Jim overseeing the transformation of our core operations and Brent laser-focused, preparing us to tackle the growth pipeline, I believe we are organized for success. I'm excited and proud that we continue to build a strong, dedicated, mission-driven team that is prepared to lead Centene through our next phase of transformation and growth. With that, I will turn it over to them and let you see for yourself.

Good morning. Thank you, Sarah. It's great to be here with old friends and to see some new -- hopefully, make some new ones. As many of you know, I joined the leadership team roughly a year ago through the acquisition of Magellan. I've long admired Centene for its focus on its customers, its strong local presence, the strength of its core products and its commitment to its mission. This is a focus that has only gotten stronger over the past year. The depth and diversity of talent and experience fortified at the local level is impressive. Centene is built to go the distance. As Sarah mentioned, we spent an incredible amount of time this year reflecting on who we are? How we got here? And where we're headed? We've been thinking about where we excel. What I like to think about is our core distinctive competencies while at the same time being honest about gaps, and more specifically, by what method those gaps get closed. It takes discipline armed with insight to take a long view, all designed to inform the assumptions, decisions and investments required in the near and longer term to make our vision a reality. The health care landscape around us is far from static, requiring the kind of cohesive agility and experience this team has and will continue to demonstrate. There are 3 key messages that I'd like to build on today. First, as the leading provider of government-sponsored health care specializing in lower income in complex populations, we're uniquely positioned to serve our members and government partners. Second, we are deliberately executing against targeted growth opportunities within each of our businesses. And third, operational excellence is crucial for our continued success. Centene was founded as a Medicaid company, and our business is built on a Medicaid chassis. It's always been our belief that health care is best delivered locally. This approach is anchored around deep and long-standing local relationships, engaged and diverse provider partnerships and community involvement that's allowed us to be successful in what is now 31 locally branded health plans in 30 states. As you can see from our 2023 footprint, long-standing Medicaid market leadership has allowed us to grow from a position of strength. We've deliberately increased our market density by gradually and methodically expanding our reach to products beyond Medicaid. As Sarah said, we lead the industry in Medicaid managed care, are the leading and largest provider in the exchange or marketplace, administer benefits for over 2 million TRICARE members and see strong opportunity for our Medicare Advantage offerings going forward. We will continue to lean into our strengths and our core competencies. In numbers released by CMS a few weeks ago, over 157 million Americans access coverage through Medicaid, Medicare and the Marketplace. Our focus on government-sponsored health care, specifically among lower income and medically complex members, positions us well to continue to grow profitably while addressing the shifting dynamics impacting health and the health care of the communities we serve. Medicaid-managed care growth in the U.S. has been impressive with spending and enrollment nearly doubling over the last 10 years, and there's plenty of runway for continued growth. Managed care program opportunity still exists as 41% of spending or $289 billion of spend remains outside of managed care. We see an opportunity in continued geographic expansion in both states without managed care, and those states with programs where Centene doesn't currently have a plan. Centene has a clear history of successfully converting state programs to managed care. In fact, 19 of our health plans started as states or in states that transitioned from fee-for-service programs or have added additional populations and geographies. To round out the map, 8 states in the District of Columbia have managed care programs where Centene does not yet participate. We consistently evaluate these programs and believe our approach and outcomes gives us a right to win in these entrenched markets. As an example, we look forward to joining Delaware's Medicaid managed care program this January. An even larger opportunity lies beyond geographic growth. Much of Medicaid spend is outside of managed care and with more complex populations, including the aged, blind and disabled, and long-term services and supports, LTSS numbers. These are medically complex populations that we understand well, and several of our state partners already entrust us to serve. Each day across the country, we're demonstrating our complex care expertise through our LTSS programs. Of our LTSS membership, we serve over 350,000 lives in a way that allows them to live in the community rather than a long-term care facility. Over 80% of our LTSS members reside in the community, and 97% of those members indicate they're satisfied with the services they're receiving from Centene health plans. If you've ever tried to move a parent or a loved one out of their home and into long-term care, you know why these are compelling results. So it bears repeating. We have unparalleled experience in working with states to expand their managed care programs. I've included an example from one of our oldest health plans, MHS Indiana. MHS entered the market serving temporary assistance for needy families and CHIP membership, Children's Health Insurance Program, in 1995. In 2011, under then Governor Mike Pence, MHS participated in the successful launch of the Healthy Indiana Plan, a precursor to Medicaid expansion that serves uninsured adults. In 2015, the state introduced the Hoosier Healthwise program, bringing ABD membership into managed care. And just this fall, MHS submitted an RFP for the state's long-term services and supports, which is slated to begin in 2024. We're awaiting the results of this RFP and hope to be selected to serve the program. I've learned through personal experience that to get states to entrust their most complex -- medically complex citizens to manage care, starts with strong partnerships that build trust and proven outcomes that back our conviction. We're proud of our leadership position in Medicaid, and we will fiercely defend it. We're fortifying our operations and leveraging deep sovereign skills, data and insight to innovate our Medicaid programs. Reprocuring existing contracts remains our top priority. In 2022, we successfully defended Medicaid contracts in Mississippi, Nebraska, Missouri, Texas and portions of California. As we look to the new year, our 2023 priorities, our operational excellence, quality outcomes, value-based care and community involvement and drivers of health, all of which you will hear more about from the panels that are going to follow me. As we shared with you previously, we are well prepared to address Medicaid redeterminations. We anticipate maintaining just under 40% of the Medicaid growth that we've seen since the start of the Public Health Emergency. We remain confident in our ability to recapture a portion of this membership through our Ambetter Health products for those members who are exchange eligible. So moving on to Ambetter Health. Centene has believed in and thus been committed to the marketplace since its inception, and we've steadily grown our ACA membership over the last 10 years. In the early days of the marketplace, we benefited from our experience and history as a Medicaid company, understanding that many ACA enrollees migrate in and out of Medicaid over time. In fact, our success in Medicaid provided the foundation for the commercial marketplace platform we offer today. Through this understanding of the consumer and our approach to network build and benefit design, we've expanded our reach to 28 states. These have been an impactful few years in the marketplace. This total participation has increased 12 million enrollees in 2021 to 14.5 million in 2022. For our part, we expect to grow our Ambetter Health enrollment by 14% to 18% by February 1, 2023. Policy measures such as the extension of the enhanced, advanced premium tax credits have aided enrollment and have benefited from markets -- and we benefited from market stability, both of which are contributing to our strong 2023 open enrollment period results. We're excited to add Ambetter Health coverage to counties in the state of Alabama and continue to see geographic expansion as a source of our growth going forward. We're also leveraging our deep experience and risk management insight to bring product innovation to Ambetter. In 2022, we introduced products outside of our core offerings including value, virtual access and tailored network products designed to better meet the needs -- changing needs of our members. In 2023, our Ambetter Select product is available in 2 new markets, 2 new states, our virtual offering in 9 new markets, and we expanded our value product in Florida and Nevada. As many of our competitors past and present can attest, succeeding in the marketplace is not easy. We've taken a measured, hyper-local approach to growth, and the management of our Ambetter products and continue to view the exchange as local down to the ZIP code level, demanding deep knowledge of each market, its providers and consumers to be successful. As Ambetter Health continues to lead and shape the individual market, we'll strive to remain the easiest carrier for members and providers and regulators to work with, all designed to build brand loyalty, and thus, real and lasting value. As I mentioned earlier, in 2023, one area of focus is on successfully attracting our fair share of membership as some Medicaid members enter the marketplace through redeterminations, which we expect to begin in February. While there are many variables that go into the size of this opportunity for Ambetter, we're confident that through the strengths of our products, our competitive position and our distribution approach, we'll see growth of a few hundred thousand members through the redetermination period, consistent with prior guidance. In 2023, we'll continue to focus on innovative products that are responsive to the needs of individual consumers and understand the changing market dynamics driven by the gig economy, part-time workers and employers moving employees into the individual market. In short, we look forward to building on our marketplace leadership position and growing the individual market, both through the Marketplace and by leveraging loyal customers and brokers to explore adjacencies to capture greater share of wallet over time. Shifting to Medicare, WellCare and our Medicare Advantage family of brands all have seen tremendous growth over these past few years. As the sixth largest carrier by membership, we see significant opportunity in Medicare Advantage supported by the growth of Medicare at large. Our focus aligns with the changing dynamics of our country, and this is important as an increasing percentage of Medicare beneficiaries becomes older and the number of individuals with chronic conditions increases. Complex care management at Centene is and will remain a distinctive capability and positions us well to meet the needs of this growing subset of Medicare beneficiaries. We see a path to growth in product and market expansion in both new and existing geographies, product innovation, strengthening our networks, and value-based relationships to drive member choice and outcomes and improving our STAR scores. We're also committed to expanding proprietary distribution channels and strengthening our relationship with value channel partners through compensation and incentive programs tied to net growth and value creation. As we work with regulators and monitor the changing regulatory environment, we believe we are uniquely positioned to build on our success with a dual eligible population through D-SNP programs. We currently offer D-SNP programs in 32 states and 24% of our members are enrolled in dual eligible special needs plans, outpacing the industry's average of 15%. This, combined with our Medicaid footprint, leaves us well positioned in our states and federal partners consider -- as federal partners consider programs and better approaches to coordinate care. So our path to success in Medicare is clear. We remain fully committed and have prioritized STAR's improvement. You'll hear more about these efforts from Sarah Bezeredi later in the program. But I'd like to again reiterate that this management team and our entire organization is dedicated to quality outcomes across all of our lines of business. As you're all aware, following several years of industry-leading growth, we approach 2023 with a focus on quality and on balancing margin and growth. Key to our strategy was reducing our dependence on higher cost distribution channels, strengthening internal direct marketing and sales capabilities and the numerous operational initiatives in flight to improve quality, customer satisfaction and member retention. Most of you know the annual enrollment period for Medicare closed last week. From what we know today, our approach largely yielded the results we expected in mix of business, higher percentage of D-SNP members and strong performance by proprietary distribution channels designed to reduce cost per sale while increasing lifetime customer value and also helping with STAR scores. With all this said, we expect to be about flat from year-end to year-end, and in the AEP, we expect to be down mid-single digits, and we expect to grow through the balance of the year, including D-SNP membership growth. As we fortify our Medicare business, our focus on operational excellence, growing the number of members served by providers in value-based arrangements, innovative benefits that address the whole health of our members and a comprehensive dual strategy that combines the strength, size and scale of our businesses will anchor our approach. I'd like to leave you with an example of our ability to fully realize our market potential by focusing on our core. There's no better example than our growth story in Florida. As you can see from the progression of our Florida Marketplace over time and market share over time built on our Medicare experience, relationships, network and hyper-local approach allowed us to layer in and build on our Marketplace and Medicare businesses. This is an approach that served us well, and remains the means through which we will grow and protect share in all of our markets. Finally, we're committed to value-based care. A cornerstone of this success is tied to our relationships with providers, and the panel discussions that follow will touch on the momentum we're building in value-based care programs more broadly. We are developing and investing in the tools necessary to engage these providers in population health, and this support remains a critical ingredient in building strong and lasting partnerships with providers, and thus, key to our success. We'll continue to grow and build from strength, leveraging our Medicaid experience, our true north, in an approach that anchors our success in market after market across all of our product lines. The result is a value proposition that is compelling, competitive and contemporary. It's now my pleasure to turn the stage over to Jim Murray, who will host a panel that details the important work being done by our value creation office to focus and fortify our operations. Jim?

Thank you, Ken, and good morning, everyone. It's great to be here with all of you. But to be brutally honest, at my age, it's great to be anywhere with anyone. I'm now into month 12 of my journey at Centene, and I continue to absorb as much as I can each and every day. I'm increasingly bullish about the opportunities ahead, particularly with the team that Sarah is assembling, some of whom you'll meet here today. So aside from my bad jokes, my job today is to provide a progress report on the value creation plan that Sarah and Drew introduced in June of last year. My 3 colleagues joining me today will then provide additional color on our progress in key areas that I'm sure are of interest to you. To make sure I'm clear on what we want you to take from our time together, I'm going to leverage some advice I received from a colleague many years ago before presenting to a room full of commercial group brokers. He said, "Tell them what you're going to tell them, tell them and then remind them what you told them at the end", so here it goes. Our value creation efforts are the foundation of our strategy. Quality is a must for the people that we serve. Innovation and modernization of our foundation will create even greater differentiation from our competitors. And finally, we are laser-focused on our core lines of business and working tirelessly to eliminate distractions. Thank you, Ken, for that sage advice many years ago. As you heard from Sarah, our value creation plan creates the foundation on which our overall strategy builds. Our focus and fortify efforts strengthen our team culture, allow us to become easier to do business with, build upon our hyper local strength and set the stage for innovation and modernization. Hopefully, this next slide is very familiar. We first shared it with all of you in December of last year, and I provided a progress update this past June. My remarks today will be focused on the box on the left, representing our work to streamline our infrastructure and transform our foundation. Obviously, these efforts will also favorably impact our administrative expenses. Anika Gardenhire will then discuss how our strength and foundation will enable innovation and modernization, which will lead to growth. Sarah Bezeredi will provide a quality update focused on our STARs improvement progress, which we anticipate will positively impact 2025 and beyond. And then finally, Colin Toney will cover the box on the right and our efforts to rationalize our portfolio, thereby enabling us to focus on the core. All of their bios are included in the information that was provided. It also goes without saying that Drew will cover these and various other value creation levers in his financial remarks. This next slide represents the financial implications of each of the initiatives the value creation office is tracking. To refresh your memory, in June, we grouped our value creation initiatives by life cycle including short, mid and long term. The initiative degree of difficulty generally aligns to these time frames. Also, our approach has been to oversubscribe these categories to ensure we meet our targets or more. We believe we are managing a portfolio, and while most of our initiatives are running favorably to plan, some are proving a little bit harder than we initially anticipated, so having plenty of room is very prudent. Short-term savings have largely been completed and will positively impact 2023 expense run rate. As we noted in the past, over half of these savings relate to the good work done by our real estate team. We do expect some minor additional savings as we delve deeper into these short-term initiatives. As you can see, short-term savings will be at least $400 million. Mid-term savings generally reflect a shifting of transactional processing from our 31 health plans to shared service organizations. It's our belief that this shift will improve economics and execution, as well as reduce complexity. All of our current centralization efforts are on plan and progressing well. There will be similar standardization and centralization initiatives as time goes on. Those are captured in pipeline opportunities in the long-term section under model market office. Since our review in June, we've added an additional item to our mid-term opportunities called IT Workforce Optimization, which generally reflects rebalancing of our outsourced vendor support. We're also in the process of evaluating similar opportunity in various of our shared service organizations. However, we do believe these later efforts will not significantly impact our savings run rate until after 2024, and are therefore also included in our pipeline. As you can see, mid-term run rate savings of $300 million plus will positively improve our 2024 expense run rate. Turning now to the section titled long term. You may recall that many of these initiatives require technological and cultural change, which obviously takes a little bit of time. I spoke to you in June about our IT platform consolidations from 5 platforms to one. That good work continues. Another long-term key area of focus relates to activating the data asset that we've assembled through serving to over 26 million people. In addition to activating this data, we intend to use the data to enable automation, drive member and provider self-service, as well as to develop capabilities and programs targeted specifically to our member and provider partners. Anika will share some of the work we are doing here in a moment. Like I shared in June, activating our data asset, thereby enabling automation and insightful self-service for members and providers, will lead to more value creation beyond the hard dollar savings contained on the slide. We will size those opportunities in future meetings. Through throw down the gauntlet in December of 2021, sharing a slide similar to the one that's on the screen, which highlighted our 2022 targeted milestones. We'll revisit that slide here in a moment and spend more time talking about our progress, but I can't pass up an opportunity to say how proud we are that every milestone has been met, and how happy I am that I could sneak that in before Drew got a chance. This progress confirms Sarah's comments of earlier: The promises we've made are the promises that we've kept Therefore, we are ready for you to measure us against the milestones on the screen as we progress through 2023. For example, in the first quarter, we plan to launch our cloud-based, next-gen clinical population health platform that we refer to as TruCare Cloud. This new platform is intended to bring efficiencies to our clinical workflow. As we roll this out to various geographies, we'll dollarize the likely financial impact and include those additional savings on the scorecard we reviewed a moment ago. In the fourth quarter, we'll launch our new Medicare appeals platform, which we believe will enable us to consistently manage our appeals in the range of 4 to 5 stars. While we're proud of all that we've accomplished to date, we do recognize that we have miles to go before we sleep. Our mission is to improve the health of the communities we serve one person at a time, and I believe that that's a journey worth taking. With that, I'll ask Anika to join me to preview our innovation and modernization plans.

Thank you, Jim, and good morning. Let me start by saying at the center of Centene exists the beating heart of 12,000 clinicians like me, 100% committed to improving the health of our communities one member at a time. And while I can geek out with the best of them, yes, I am fascinated by all things data from thick data to big, to subbranches of data science like natural language processing, and I know at least one other person remembers that George Jetson was born in the year 2022. But kidding aside, as a clinician, I view everything we do through the lens of a person-centered journey, and the opportunity to deliver on the promise of data-driven innovation at Centene humbles me every day. While I will be sharing with you a few recent developments on our digital transformation journey, I want to emphasize that we have and will continue to keep the member at the center of everything we do. As we look forward to the next 5 years, we hope to emerge as a trailblazer in the development and purposeful use of industry-leading data and technology solutions to serve Medicaid, Medicare and Marketplace populations. So how are we doing this? We will start by simplifying our technology ecosystem through our value-creation initiatives like platform consolidation. Building on this, we are tapping into our rich data and leveraging advanced analytics to power solutions like clinical decision support and population health tools, generating data-driven insights that support appropriate utilization and lower costs. By developing simplified, secure and differentiated experiences for our members, internal teams and partners, we can drive success across the care team and achieve the best possible outcomes for our members. Under Sarah's leadership in 2022, we brought together several disparate departments to align, centralize and accelerate this work. With the formation of the new Digital Solutions and Products department, we are focused on the continued use of data and technology to transform our business and the ways in which we serve, driving exponential value to our members, partners and shareholders. We have historically used call centers to manage provider issues like claims, inquiries and data visibility and quality concerns. And although effective, this process introduces time, cost and relationship impacts. By advancing robust self-service tools for our provider partners, we can mitigate these impacts, making it easier for providers to work with us. As you have heard from Sarah, our provider partnership strategy will be critical as we move forward, and we have already begun the work to advance it by placing innovative tools at the fingertips of our engagement professionals and provider partners. Into our Provider 360, a new provider relationship management solution that coordinates current capabilities and serves as a platform to power ongoing innovation. This tool will support providers through a streamlined onboarding process, collaborative issue resolution and much more. This is just one example of the untold value that Jim referenced earlier. I want to leave you with a story that demonstrates the meaningful impact data-driven innovations can have on our lives. Imagine there's a little boy at home, asleep in his room. He has asthma and suddenly, he starts to have difficulty breathing. Luckily, he's wearing a sensor, and that sensor triggers to thermostat in his room to raise the humidity and the temperature. But while it helps, it doesn't quite resolve his breathing difficulties. Measuring limited improvement, that same sensors triggers a notice to release aerosolized medication in the room. And this time, it works. He, nor his parents had to wake up that night. There was no panic. There was no visit to the ER or to the urgent care. However, this event did not go unnoticed. The underlying data were sent to his providers. His providers were alerted and informed, and this data will be used to support his care team in managing his asthma protocol. This is our future, and the technology already exists to make this are today. At Centene, we are uniquely positioned to make this a reality for our members and effect measurable, positive change in their lives that honors their diverse needs and values. Thank you. I'll turn it back to you, Jim.

Anika, thank you. That was an amazing story, which supports the statement that I made earlier about serving the communities that we serve one person at a time, and it's a journey worth taking. Next, Sarah Bezeredi will review the basic of some STARS, and then highlight our progress to date.

Thank you, Jim. Good morning, everyone. I'm delighted to be here this morning to tell you about this, the good work that's taking place in quality. As you heard from Jim, quality is a cornerstone to the success of Centene, and a large focus across the organization, especially related to our Medicare STARS ratings. Since joining the organization a short 16 months ago, there's been a significant change in every area within Centene that touches our Medicare members. Members deserve nothing less than high-quality health care. As much as anything, the mission of delivering quality helps shape the way providers and health plans function day to day and strive to meet members' needs and expectations. I'm energized by our focus and the direction we are headed to improve our members' overall health and experience. I'm also inspired by the diligence with which we are solidifying our partnerships with providers across the country to help deliver value to our members. The Medicare STARS program, governed by CMS, aims to elevate the accountability of health plans and serves as a road map for us to shape Centene's Medicare program in a way that makes it easier for providers to do business with us and assist them in helping our members lead their healthiest lives. What's important to understand is Star Ratings represents a multiyear process with hundreds of millions of dollars tied to health plan performance, which is incumbent upon health plan processes, provider engagement and member well-being. Next year, data will be collected and finalized for services provided to members throughout the 2022 calendar year. Performance on the various measurement areas, which we refer to as performance chapters, will be evaluated and represent our 2024 STARS rating. These ratings will determine the amount of quality bonus payments to the health plan, which will be paid out in 2025. This is the first of 3 cycles we will embark on to reach our STARS goal. The performance results that were released this past October impacts 2024 revenue, and was based on activity that occurred during the 2021 calendar year and concluded in June of 2022. The performance results that will be released in October 2023 will impact 2025 revenue and are based on activities occurring now and into 2023. In recent years, CMS has made significant revisions to the STARS Rating Program, placing a greater emphasis on member experience and day-to-day health plan operations. The perceptions and insights from our members regarding the care received from their physicians and interactions with the health plan make up a larger portion of our overall STARS ratings. As we enter the next STARS rating cycle, there are 2 major areas of focus: one, the CAPs chapter, which is a series of survey questions that measures the members' experience. And two, the administrative and operational chapter, which measures health plan day-to-day functions. Combined, these 2 chapters now account for 60% of our overall Medicare Stars rating. Quality improvement represents an integral part of our organization's foundation. Ensuring we continue advancing our mission of achieving better health outcomes for our members has led to recent investments in key initiatives involving people, processes, technology and partner management. Our path forward starts with people. We brought a significant amount of talent into Centene, who have a proven track record of driving successful outcomes and quality. We have increased staffing and critical customer-facing areas. We went on to improve processes within operational business units to drive more efficiency and effectiveness. And finally, we developed advanced analytics to orchestrate pivotal member engagement, increasing clinical outcomes and satisfaction in the care being delivered to our members. We're using these tools to better support and strengthen partnerships with providers to improve access to care and the quality-of-care, members receive. When it comes to value, we are increasing our value-based provider engagements because we know those enhanced partnerships drive higher quality of care. The key takeaway is improvement takes time, and we are dedicated to our purpose. Leveraging strategy around investments in people, processes, technology and key partnerships puts us on a realistic path forward towards our goal of achieving 60% of members in a 4-star rated plan over the next 3 rating cycles. I'm confident in our plan. Our team is motivated, and we're excited to be part of this quality journey.

Leadership in our STARS improvement efforts. I look forward to celebrating with you when we get to the 60% level. Next up is Colin Toney, who will walk us through the work he and his team are doing to rationalize our portfolio, enabling a stronger focus on our core businesses.

Thanks, Jim. Hello, everyone. Today, I'm going to tell you about how we are aligning the portfolio of companies we own with our strategy and about the substantial progress we made in 2022, which is summarized on this slide. We also want you to know that we continue to evaluate and pursue potential acquisitions. Given our change in strategy, last year, we embarked on a comprehensive portfolio review process, through which we are evaluating whether we need to own each of the non-health plan assets in our portfolio. We've applied a consistent lens to each asset to determine what we want and need to own based on each asset's ability to help our core business. We finished most of the review so far, and for many, but not all of these businesses, the answer has been to divest. As we've reached conclusions to divest, we've acted quickly to find the right homes for each business and the right transaction for Centene, and our main objective is to allow our company and our management team to sharpen our focus. Since late last year, we've announced divestitures of majority stakes in 5 transactions in the pharmacy, provider and payer services industries. Four of these transactions have closed, including Ribera Salud, our Spanish and Central European businesses last month, and Magellan Rx this month. The fifth, Magellan Specialty, was just announced in November and is expected to close in the first half of 2023. These 5 businesses collectively represent approximately $6 billion of annualized revenue and the 5 transactions are expected to generate aggregate proceeds of approximately $4 billion. For some of these businesses, Centene can benefit from ongoing partnerships. For those companies, our deal template is to get the best of both worlds: A market price for the asset and an ongoing strategic partnership, which provides additional value for Centene over time. This way, we can continue to benefit from these businesses doing what they're good at without having to own them. Today, you'll hear us talk about partnerships a few times, especially in areas where we've decided we don't need to own businesses because we are focused on leveraging partnership as a discipline to execute on our strategy. Let me hit on 2 examples. First, simultaneously with our recently announced sale of Magellan Specialty to Evolent, we announced a contractual partnership with Evolent, which builds on our long-standing relationship with Magellan Specialty, and our increasingly strong relationship with Evolent's New Century Health business. We're expanding some of Evolent's products and services to Centene's markets and members, and we're consolidating various contracts into one larger contractual relationship. And of course, we've got a market price for the asset. Second, in late 2021, we announced the sale of a majority stake in USMM, a home-based provider business. We built a strategic partnership with the industry leader in home-based models and investors who intend to invest significant capital to ensure the success of the business. The transaction positions USMM as an independent company while also preserving a minority stake for Centene, allowing us to participate in future value creation. As part of the transaction, we expanded our commercial contract to serve additional high-acuity Centene members and drive cost savings for years to come. Across all these transactions, we've successfully achieved our financial goal of having a neutral or positive aggregate impact on adjusted EPS by repurchasing shares with the proceeds. Now, let me leave you with 3 concluding thoughts. First, it's been a busy year, and we're proud of the huge progress that we've made to date. Second, we're not finished with the portfolio review work. And third, we continue to seek out and evaluate attractive acquisition targets, which clearly fit with our go-forward strategy. Thank you.

Thank you, Colin. I can attest to the fact that you and your team have been very busy, and fortunately, the results you're achieving are amazing. So I'm going to follow Ken's sage advice from the floor, and this is the remind them of what you told them part. First, we delivered on our value creation efforts in 2022, and value creation remains a pillar of our long-term strategy. We are using data and technology to transform the ways in which we serve our members, partners and providers. We are executing operational improvements and making strategic investments to improve our STAR ratings. And finally, we have successfully divested non-core assets, and we'll execute on transactions that allow us to focus on our core. Next up is Panel 2. They'll talk you through important information about each of our lines business. Thank you for your attention.

Okay, we're going to pivot, move to a conversation around growth. And before we start, I'd like to take the opportunity to introduce the panel to my right. You've got an opportunity earlier. I'm going to start with Brent Layton. Brent is most recently our President and Chief Operating Officer, announced this week going to be gliding into retirement, and I used the word gliding very gratefully. Brent has had an amazing career, and I'd like to pause for a moment to -- on behalf of our over 80,000 employees and the millions of members we serve, I want to congratulate you and thank you for your incredible accomplishments on our collective behalf and your dedication to our mission. Brent, as you probably know, has built the industry [indiscernible]. A lot of that going around. Brent has built the leading business development team. I tell you, our own version of the Georgia Bulldogs. But I'll tell you that it's -- the part of what makes this organization powerful from market to market is the deep local knowledge not only his team brings, but the opportunity to leverage innovation and insight to help us not only procure new contracts but protect the ones we have. And so I'm personally, in my new role, enormously grateful for your willingness to give us the time to make this transition smooth. And we've already enjoyed a relationship that I think is going to allow us to demonstrate what that can mean for the broader organization as we move forward. Thank you. Brent will now be a senior adviser to Sarah, and will remain in the office of the CEO. Next to him is Dave Thomas. Dave has also recently been promoted. He's now -- he was leading our Markets, and now, he's the CEO of Markets and Medicaid, one of our 3 main lines of business, came to us from Fidelis. Katherine Kirby -- Kevin Counihan, who is the CEO of Ambetter Health, broke his ankle and was unable to travel. Thankfully, Katherine, who's the Chief Operating Officer, also recently promoted, has agreed to join us today, and we'll -- as Kevin will attest, fill in beautifully. And finally, Rich Fisher, to my immediate right. He's the CEO of WellCare or our Medicare Advantage lines of business. So let's jump right in. Brent, I'm going to start with you. The group today has heard a lot about what's making this business tick now. Let's pivot and think about how do we ensure Centene is positioned to win in the second half of the decade?

First of all, thank you for your kind comments. I've been at Centene for 2 decades for 20 years, and when I started as a consultant on '01, Centene was in 3 states, and we were well below $1 billion in revenue. And to see the company today well in excess of $100 billion in 30 states for Medicaid, the largest Medicaid managed care company. We started from scratch with Ambetter in the exchange day 1, and now we're the largest exchange provider. And we've entered Medicare Advantage in a very large way. Absolutely humbling, and I'm just so appreciative of the opportunities I've had a Centene. But to answer your question, we've always been a market maker, and it started in Medicaid. We were there from the very beginning. In fact, in a lot of ways, I believe in my home state of Georgia, the RFP came out in '05. It was the first state that went to mandatory statewide managed care period and an RFP process. That is the norm of how things are procured today. That set the pace. But we also learned there our business development strategy. We learned the importance of being on the ground, boots on the ground. We learned the importance of having local relationships, of knowing the community, of working with providers, and that has fueled us. We learned something also about being local. Dave, you and I talk about it all the time.

Yes. I mean, I think our local approach is a huge advantage to us, and maybe just a little bit of an explanation of what we mean when we talk about local. So we have teams serving our providers and our members that are literally living in the communities that they serve. And that's a big advantage to us in a lot of different areas, one of the big ones being provider services, where being in the community puts us in a really good position to serve the safety net providers that are the foundation of our networks. Particularly talking about FQHCs and also community hospitals, which is a big, big component of the networks. Probably just as importantly, our local leadership teams are not only living in the communities that they serve, but they're also empowered to make decisions locally. So they're not having to run back to some centralized authority to get approval to make decisions or response to request. So those are really major advantages. We get really good feedback from our providers and from our regulators because they can go to our leadership teams locally with requests and get them turned around really quickly. So it just makes us much more agile and responsive on the ground.

Ken, this is why in Medicaid, we feel strong about our future for more growth and success. But then on the exchange, when we entered the exchange, we stayed in. Some people came in, they left, they came back. We've been from day 1 and never left. And what we realized is that the exchange population's essentially the brothers and sisters of Medicaid. And with it, just as you had in your slide, you talked about Medicaid chassis. That chassis, that approach with the provider network, that understanding of the community and of our future members and of our members have served us well and will continue to serve us very well under the company. I think that sky absolutely is limit, and we'll continue to grow. And yes, we got to Medicare Advantage late in the game. But nonetheless, it's those local relationships, knowing the community and really knowing the provider in a partnership that's going to allow us to really fuel our growth throughout this decade.

Right. Thank you. So let's get the rest of the gang involved. Let's talk about the degree of confidence you have, and our ability, which we talked about the success we enjoyed in Medicaid. It's a strong platform for growth. Describe how that -- we can build on that both from the perspective of the local markets, and then we'll move to each of the lines of business.

Yes. I mean, I again go back to the local approach, giving us a major advantage. So we've been in these communities, building Medicaid from the ground up. We've got great provider relationships. We've got great relationships with our regulators. We're also well known in these communities that we're serving. And so when we go in and we want to expand into Medicare or we want to expand into Marketplace, we already have a ground game. Providers already know us; regulators already know us. So when we're trying to build networks, we're trying to get regulatory approvals, we're at a major advantage. And then we're set up well for growth, again, because the communities already know us.

Yes. Katherine, can you build on that?

Yes, absolutely. I mean, Ken, I think you [indiscernible] product really local level. And what that really means for us is we look at how we're building networks, the products and offerings are that we are [indiscernible] to that. And frankly, our broker -- our sales distribution, we are finding the community, getting them signed up [indiscernible] product. And you guys, that was a really brilliant answer that you all missed. Find me after we end, but absolutely. We have seen the value down to the ZIP code levels.

Yes. The point she makes about loyalty, both at the member level and the producer level is very, very powerful. And I think something we don't tend to speak a lot about. But having had a lot of experience selling insurance over the years, I can tell you that is also a very local game as well. While you could leverage technology to do that, the ability to understand that local market down to the ZIP code is powerful no matter what medium is used. Rich, add a little color for Medicare?

Yes, so both you and Sarah touched on this. There's a long runway for these complex populations to enter into Medicaid and managed care. Why is that important? We have a 97% overlap of our Medicare and Medicaid footprint today, over 500,000 underlying duals. It's a significant opportunity for us. And Dave, back to your point about the local relationships, why is that important to us, right? Those relationships we have with states and providers, that affords us a seat right at the table to be able to help them craft the dual integration models that are successful for them and meet the needs that they would like.

Great. Dave, you and I have talked so much about provider contract and provider partnerships, and I think we spend most time talking about value-based care. And yes, risk and yes, capitation. Won't you add to that? Let's start out with Medicaid here.

Yes. So on Medicaid, value-based care is a huge component of what we do, and we already do a lot of it. We've got 40% plus of our Medicare population in BBC arrangements, that's about 6.4 million people. So a lot of Medicaid enrollees already in value-based, and that's only going to grow. And the reason it's going to grow is value-based care is the best way that we have to align the incentives of us as the payer and the providers as the folks that are servicing our members. And particularly in the areas of medical management, so the management of the utilization of the population, quality, so ensuring that quality of care is being provided to our members. And risk adjustment, which is a big one because it feeds into in premium. So having the provider and the payer aligned through a value-based care contract is the best way to make sure that everybody is operating as efficiently as possible.

I mean, Katherine, we know that at the end of the day to be successful in exchange, you've got to have a strong provider network. You got to have a robust network. But are you doing value-based today in the exchange?

We are. We absolutely are. We are not quite as far along as our friends over in Medicaid, but we have about 7% of our membership right now in value-based arrangements, and really expecting to grow this out to about 10% to 15% in '23. It's a little more complicated due to risk adjustment, but we absolutely see the impact that it has on the quality of care that's provided to our membership. And along with CMS, that's something that we're really looking to continue to drive.

Rich, obviously, value-based risk capitation is the core of Medicare Advantage. What are you doing today there?

Yes, yes. It's been a core part of the strategy, has and will be into the future. We've got about 40% of our members across 3/4 of our states today that are in a value-based arrangement, and why is that important? It's important because it delivers better health outcomes, better quality, lower cost, and we see better growth and retention with those value-based provider relationships.

Great. So let's stay on the provider theme. And as we think about our long-term provider strategy, we said that owning providers is no for today. But is it off the long -- is it off the table longer term, Brent?

I think it's important to realize that really the mix of Centene and where our revenue is coming from, and roughly 65% of our revenue comes from Medicaid. And our largest provider in Medicaid are barely qualified health care centers or community health centers. They're not for profit, and they are core to our strategy. We couldn't buy them if we wanted to. They can't be purchased from that standpoint. At the same time, we always are, in our state contracts, have to focus on improving access, having a strong network. And if we really own a certain amount of practice, it's ultimately, it may be restrictive and may hurt us in meeting the needs of our state partners. What we do believe in is provider partnerships and enabling the providers so that we can focus on quality, focus and value-based and jointly come together for the betterment of the members from that standpoint. No, it's not off the table. Actually -- in South Florida, we actually own clinics there. CMG, and CMG in so many ways, is a part of our success in the exchange in South Florida today from that standpoint. But overall, looking at it, we have -- we're following our mix of business, our revenue and what we need to be successful in that area.

I would add that we talk a lot about currencies, and the currencies exchange and relationship we employed with our provider partners are many and varied. You heard from Anika about the power of the digital platform we're building. You've heard from Sarah about the insight that we can provide with data and then help them operationalize that. I think that all builds powerfully on the perspective you shared with us today.

No doubt. So organic growth, right? The key of what we've been doing for years and been able to grow the company, and great examples in Medicaid. So tell me how you see that?

Yes. So I mean, first of all, there's a lot of runway left in Medicaid, there's a lot of growth to be had. A lot of that is in the high acuity populations that I think Ken talked about earlier, and talking again specifically about things like our programs like long-term care, ABD, SSI, Foster Care. There's still, I think, 40% plus of the Medicaid spend and fee-for-service. So a lot of room to move these populations or continue to move these populations into managed care, and states are continuing to do that. The most recent examples, as you know, the Indiana RFP that we just submitted includes long-term care, and then Oklahoma that just came out includes foster care. So states are continuing to move these populations into managed care and a lot of opportunity there. I would also say there are still a number of states that don't do Medicaid managed care at all so those are opportunities down the road. And then there are states that do mitigate managed care but have not yet expanded Medicaid, so another opportunity there. So I would just say, in summary, lots of opportunity in Medicaid going forward.

So Katherine, obviously, we're growing at Ambetter, our exchange product, but tell me more about organic growth and where you see it going.

Sure. So excited to be finishing up our 10th open enrollment in the Ambetter product. We've been here the whole time and continue to grow. And we're really looking at organic growth kind of in 2 ways for Ambetter. We're looking at it short term, we've seen a lot in the last few years, a lot of policy that has been helpful to that. The Enhanced Advanced Premium Tax Credits, of course, taking a look at things like family glitch, but we're also taking a look at some of our sales strategies thinking about some of the second tier rural cities, really taking a look at flex and gig economy workers, how they're purchasing, what they're looking for in their insurance. And then longer term, we really see the Marketplace as a really viable solution that can meet some of the changing needs of employers and employees as they're really thinking about how they control costs and are a little bit more able to customize their benefits. So -- and of course, it's always been viewed as a platform to kind of add some supplemental coverages and services as well. So lots of growth and exciting times.

So Rich, when Centene purchased WellCare, and we closed on it in February of '20. I think I'm right. You can argue me if I'm wrong. We had about 949,000 Medicare Advantage members. And today, these two basically short years later, we have 1.5 million, tell me about continued growth.

Yes. So as we look out into the future and Sarah touched on this in her remarks, the pie of Medicare is going to continue to grow for the foreseeable future, that total eligible population. We see large geographic expansion abilities for us going forward. We're only covering about 80% of the 65 million eligibles today in our footprint across 36 states. We're going to continue to innovate products, right? We're going to meet the needs of those members. We're going to design those products such that we can get them.

Great. Listen, hopefully, this was helpful as you begin to think about how to parlay everything you heard about fortifying our foundation and rightsizing our cost structure to create the kind of platform for growth that we believe is very compelling. I'd like to now ask Sarah to come back up and wrap up the first part of the morning before we send you off the break.

Thank you, Ken, and thank you to the talented Centene leaders who spoke with you during the first part of the program. Over the last year you have seen this team in action. You've seen the progress against our operational and financial goals. You've seen Centene show up for our members across the country. We will continue to carry this positive momentum into 2023, positioning us for continued earnings growth and the creation of shareholder value. This morning, you've also heard commitment to our core business. As Ken described, we are executing against a targeted pipeline of growth opportunities within Medicaid, Marketplace and Medicare. You've heard our focus has sharpened on operational excellence with the many initiatives being explored, executed and relentlessly tracked by the value creation office. And Jim provided you with a fresh set of milestones that will propel us forward in 2023. Finally, hopefully, you've heard excitement. Excitement for the vast opportunity we see for our businesses and for the industry in 2025 and beyond. We're about to take a 15-minute break. But before we do, we'd like to share something that has meant a lot to us over the last year. [Presentation]

Okay. With that, we're going to go into a break and we're going to give everybody 15 minutes. We're running a little bit behind schedule. So if folks could get back towards their seats around 10:25, that would be great, and we'll get started with the second half. Thanks so much. [Break]

We're going to get started in just a minute or two. So if you could take your seats, that would be great. Thanks so much.

Well, welcome back. Obviously, today is a day where we talk a lot about what we've done and what we're going to do. But when you look at that video and just the impact on the community of Uvalde, that just tells you who we are at our core. And I just want to tell you before I start, what an honor it is to work for such an incredible team and company that is so mission oriented. So with the recent election provided us a great deal of clarity regarding health care policy. Number one, the ACA is here to stay, and it is firmly embedded within the U.S. health care system. Number two, the Biden administration has been successful in strengthening the ACA and providing comprehensive coverage to more Americans than ever before. Medicaid and the Marketplace had never been more popular when it comes to the electric and also repeal and replace and Medicare for all are no longer serious policy pursuits, even though there's still going to be a few politicians on the far end of the political spectrum that may signal support for these efforts. Divided government limits the ability of the 2 political parties to enact major structural reforms to the health care delivery system. We believe this will create a certain degree of stability for the next 2 years. At the same time, we expect that there will be significant debate but not much action on legislation to tackle rising prescription drug costs and behavioral health. We also expect the discussion around the timing in guardrails for the ending of the public health emergency and the start of Medicaid redeterminations, and we will continue to work with regulators in states to assist with outreach and engagement efforts to ensure continuous coverage for affected people. The ACA has been in effect for over 10 years now. Throughout this time period, headline volatility has led to some questioning its viability, but in reality, the federal government has fortified the Medicaid and Marketplace chassis to ensure that both the poor and working poor have access to high-quality comprehensive and affordable health care coverage. According to the Kaiser Family Foundation over the period of 2014 to 2022, total Medicaid and chip enrollment increased from $61.7 million to nearly $90.5 million. And then there was a recent HHS report that noted that over the same period, Medicaid's expansion population has increased from 6.3 million to 21 million. And the Marketplace, well, that has grown from 6.4 million to now over 14.5 million individuals, 14.5 million. When 1 party holds the majority in Congress and the White House, states tend to take a backseat in their health policy pursuits as they wait to see what Washington does. We saw that during the ACA debate, repeal and replace and even over the last 2 years when Congress was exploring the public option and managing through the COVID pandemic. With Washington likely to experience gridlock over the next 2 years, we anticipate greater activity at the state level. The 2022 elections proved how difficult it is to unseat an incumbent governor, only 1 incumbent lost, and that was in Nevada. With so many incumbents winning, we expect legacy, rather than reelection, to be top of mind for many of them, in which case, we see greater receptivity to pursue health care policy changes that improve quality and coverage. Medicaid continues to have broad bipartisan support at the state level. Now there's 40 states having expanded coverage to 133% of the federal poverty level. We expect North Carolina to seriously consider becoming the 41st state to expand during the upcoming legislative session. States will also continue to look at managed care for their higher acuity populations, the age, blind and disabled residents as well as long-term services and support. In many states, where legislatures have not expanded Medicaid coverage, voters have passed Medicaid expansion via ballot initiatives, including Missouri, Oklahoma, Utah and Nebraska, to name a few. As a matter of fact, each time these have gone to a ballot initiative, they have not lost. Oklahoma is not only in the midst of expanding their Medicaid program, but they are also moving to a Medicaid managed care model, just like North Carolina did before them. Overall, Medicaid and health care coverage policy did not play a central role in state campaigns, except for the gubernatorial races in Arizona and Oklahoma. In Arizona, Kari Lake stated she would end Medicaid expansion, while Governor-elect Katie Hobbs, said she would protect the access program. In Oklahoma, Governor state was reelected for a second term. During his campaign, he advocated to moving the state to Medicaid managed care, while his opponent campaigned on stopping it. As an organization, Centene continues to believe that good policies are good politics. In 2022, great strides were made when it came to access and affordability for those below 400% of the federal poverty level. On the Medicaid front, states can now provide postpartum coverage for Medicaid recipients. 27 states have now implemented this, and we believe that 7 more intend to do so in the coming months. On the Marketplace side, the Enhanced Advanced Premium Tax Credits were extended through 2025. These provide a substantial savings on monthly premiums making the Marketplace coverage now more accessible to millions of Americans. Looking at the Kaiser Family Foundation data on 2022 open enrollment, average monthly premium started at $524 for customers eligible for APTCs and this drops to just $77 a month once those credits are applied. We were also pleased to see the Department of Treasury fix the so-called family glitch that prevented some people with employer-sponsored coverage from qualifying for APTCs. While more work needs to be done to maximize the potential of this fix, these 2 policy changes reflect the administration's continued support for the ACA and commitment to accessible health care. Another area where our expertise will be critical is addressing the dual eligible population. As federal and state policymakers consider how the environment should evolve to best serve duals in 2023 and beyond, we anticipate continued opportunities to engage and inform dual-eligible coverage models. Congress in the administration took a tremendous step in reducing billing exposure to consumers with the Surprise Billing Act. And while the courts have created some uncertainty regarding how costs will be determined, Centene continues to support implementation of the surprise billing legislation in a way that, number one, protects consumers; number two, increases network participation and lastly, lowers overall health care costs. In 2023, with health care policy opportunities more limited at the federal level, we expect activity to pick up at the state level. Although the date for eliminating the PHE remains unknown based on our experience and leadership in Medicaid and the Marketplace, we are well positioned to assist states with their consumer outreach and engagement efforts to help ensure continuous coverage throughout the PHE unwinding. Centene continues to partner with states to understand which members may be disenrolled from Medicaid, but could either retain coverage through the Marketplace or who may even be newly eligible for Medicare coverage. We believe the recently proposed rule by CMS will improve member protections and the flow of member data during the unwinding of the PHE. This is going to strengthen our ability to mitigate reductions in Medicaid enrollment when maintenance of effort requirements end. On the pharmacy front, we anticipate continued activity in the states aimed at improving transparency and addressing high drug cost prices. Consistent with previous legislative sessions, we do expect to see pharmacy carve-out proposals in 2023, and we will continue to take this opportunity to educate legislators on the cost and quality benefits of integrated care and management, which, of course, includes pharmacy. Earlier, you saw a video of the meaningful impact we are having on the lives that live in Uvalde, Texas, where our superior health plan serves over 6,000 people or about 1/4 of the county. It is one of many examples of how the Centene Charitable Foundation is working to better meet the needs of our members. You've heard Sarah talk about our hyper local approach to health care delivery and now our Centene Charitable Foundation aligns with that same mission and focus. Foundation investments are now benefiting economically challenged communities and supporting a long-term vision, in which we collaborate with other corporate partners to provide services and support individuals with the greatest needs. In addition, each one of these unique partnerships offer opportunities for our employees to engage in Centene's mission as employee ambassadors contributing their time, energy and resources through a range of programs strategically aligned to support these projects. Policy, performance and purpose are all now fully aligned at Centene. So in conclusion, I want to leave you with 3 core premises we see on the political front as we move into 2023. Number one, with a thriving and firmly embedded Marketplace and divided government in Washington, major structural health care reforms are unlikely. Number two, Medicaid enjoys broad bipartisan support, and the administration is looking to both Medicaid and the Marketplace as the programs of choice to provide access and coverage to the poor and working poor. And lastly, our hyper-local approach aligns with the expected increased policy activity at a state level to expand this access. With that, I would like to introduce Drew Asher.

Thank you, Jon. Let me start with a 2022 financial update and then provide a detailed view into the future, including 2023 guidance, 2024 perspective, and then our new long-term earnings growth rate algorithm for 2025 and beyond. As you've heard today and throughout 2022, this has been a very busy but satisfying year in the context of providing a sound foundation for the future. You may recall that our original 2022 premium and service revenue guidance was a midpoint of $131 billion with $5.40 of adjusted EPS. Since then, we have most recently guided to $135 billion of premium and service revenue and $5.70 of adjusted EPS, an increase of 5.5% since our original guidance. We have shown over 500 basis points of commercial HBR improvement in the first 9 months of 2022, and we're not done. In 2022, we have initiated, sold and closed 3 divestitures consistent with what we promised you a year ago. And we have deployed proceeds to both reduce our share count and our debt load. Since year-end through today, we have bought back 34 million shares of our common stock or nearly 6% of the entire company. Year-to-date, we have lowered debt by $600 million and reduced debt to adjusted EBITDA to 3.0x. And we picked up an investment-grade rating along the way that will be very valuable to Centene in the long run. We made promises and we kept them. In the back half of 2021, a number of you were asking us how you could track the company's progress of the value creation plan in 2022? As a result, we showed you a time line at our December 2021 Investor Day that look like this, except there were no checkmarks at that point. In the past year, as Jim previewed, we have made meaningful progress on value creation initiatives and checked all of the 2022 boxes, including operating model changes, early-stage platform consolidation activities, meaningful real estate actions, a strong PBM RFP process and outcome, multiple transactions and big share buybacks, but most importantly, creating momentum and planning seeds to bear fruit in the next couple of years. There is a lot more to do, but year 1 was a pretty good foundational year. With that, and 2 more months under our belt, we are on track with our latest guidance provided on our Q3 earnings call. Through November, utilization remains in check. Influenza has been manageable, and we are reaffirming our adjusted EPS range of $5.65 to $5.75 for 2022. Our strong performance in 2022 creates momentum for what really matters 2023 and beyond. I know you guys have read ahead, and you've seen that our adjusted 2023 EPS guidance encompasses the current 2023 consensus, but let me spend some time reviewing some of the key assumptions and drivers of our 2023 guidance. We'll get to revenue, HBR and SG&A bridges in a minute, but here are some of the larger assumptions in our 2023 plan. For budget and guidance purposes, we assume that redeterminations recommenced February 1, 2023. We know that the 60-day notice was not provided in mid-November, and there's a possibility or maybe even likelihood that redeterminations get pushed out further. But until we get through this calendar year, clear of any legislative action, we are sticking to February 1 in this round of 2023 guidance. We have assumed a 2023 composite rate increase in Medicaid of 1.4%, a little higher than 2022, which came in at about 0.9%. We are seeing and expecting strong membership growth in Marketplace from sound execution as well as the exit of a couple of competitors. This assumed membership growth of 14% to 18% peak to peak is higher than what we were expecting a couple of months ago. We also expect margin expansion based upon the bids we filed this past summer. In Medicare, we are expecting HBR improvement based upon our intentional bid designs and higher STARS revenue in 2023. Based upon what we are seeing in the annual enrollment period, we expect to be about flat from year-end to year-end. In the AEP, we expect to be down mid-single digit and then grow throughout the rest of the year, including decent membership growth. Overall, this flat full year expectation is lower than the low to mid-single-digit membership growth we were expecting prior to the AEP, but coming off of a 2-year period where we grew 50%. Our priority was margin, operational execution and quality scores, including rebalancing distribution channels. The impact of these decisions will benefit our Medicare business in the long term. On capital deployment, we expect to deploy free cash largely to share repurchase in 2023. In our guidance, we don't include any future divestitures. So for instance, the sale of Magellan Specialty, that we announced in November, is not reflected in the guidance elements though we would expect the net effect to be neutral to EPS. We continue to go through the portfolio review process that Colin described, and we will certainly consider bolt-on acquisitions in 2023 for assets consistent with our strategic plan. Our starting point for premium and service revenue, our 2022 guidance midpoint, is $135 billion. If we remove the revenue from the 3 divestitures that have closed in the past 6 months, the starting point is $131 billion. We expect strong growth in Marketplace and to pick up some revenue yield in Medicare Advantage. Medicaid organic growth, excluding the impact of redeterminations, is forecasted at $3.7 billion. This includes new populations such as Delaware and Missouri expansion, same-store membership growth and rates. Our run rate estimate of the impact of redeterminations is still approximately $8 billion with $4.5 billion coming out of 2023 and the remainder in 2024. Obviously, that is dependent on both the start date and the slope lines we are estimating on a state-by-state basis. And finally, we are forecasting a little over $2 billion of revenue reduction from pharmacy carve-outs from managed care in a few of our Medicaid states. The overall result is reasonably stable premium and service revenue in 2023 despite redeterminations. Turning to the HBR bridge. This graph shows the impact of the business lines on the consolidated HBR. Our overall HBR is expected to improve approximately 30 basis points at the midpoint from 2022 to 2023. This is driven by HBR improvement in Medicare Advantage and Marketplace. Underneath the Medicare businesses, the Medicare Advantage HBR is improving over 100 basis points in our 2023 guidance, consistent with our bid strategy. Overall, our Medicare businesses represent approximately 17% of total company Premium and Service revenue in 2023, and our commercial businesses represent approximately 15% of Premium and Service revenue. Now on to SG&A. There are a few moving pieces, largely driven by mix. Medicaid, which operates at a structurally lower SG&A rate, is shrinking in 2023 due to redeterminations, while Marketplace with distribution and exchange fees is growing and Medicare is flattish. Divestitures also impact the mix. The remaining change represents a more substantive reduction of approximately 10 basis points in the aggregate SG&A due to leverage from the value creation initiatives, net of 2023 investments. Here is our traditional guidance table reflecting everything we just covered, resulting in an adjusted diluted EPS in the $6.25 to $6.40 range consistent with where 2023 consensus happens to be. Since we pulled forward some of the 2023 share buyback into late 2022, we provided a footnote of where we expect to end 2022 share count on a fully diluted basis to help in your modeling. Other metrics for 2023 include a lower cost of services ratio as a result of the mix of our divestitures; strong investment income as a result of Fed rate action during 2022 annualizing into 2023; slightly higher interest expense for the same reason related to floating debt; lower CapEx as we wind down building things; and a debt to adjusted EBITDA at less than 3x in 2023 as EBITDA grows with a flat to slightly decreased assumed debt level. Beyond 2023, as we covered on the Q3 call of late October, we expect strong adjusted EPS growth in 2024. Depending on the outcome of the California protest, our 2024 targets are between 11% adjusted EPS growth at $7 and 19% plus adjusted EPS growth at $7.50 plus, both relative to the 2023 guidance midpoint. So no changes from what we discussed on our Q3 earnings call, but we thought we'd reiterate some of the headwinds and tailwinds we have previously covered for 2024. As Sarah highlighted, we are excited to lay out a long-term framework for beyond this Focus & Fortify time period for Centene, a time period when divestitures and redeterminations are behind us and we return to steady growth by seizing the opportunities in the growth areas of managed care government programs. We believe we can grow consistently adjusted EPS at a 12% to 15% compound annual growth rate from 2025 through the end of the decade or in other words, the foreseeable future. How will we do that? By growing revenue 7% to 8% plus getting 1% to 2% leverage on growth and continue slight margin expansion plus deploying capital for an additional 4% to 5%. We will migrate from the current focused and fortified time period to expand and transform time period in 2025 and beyond. Drilling down on the earnings growth algorithm, how do we grow revenues 7% to 8%? Let's start with Medicaid. To summarize what Sarah and Ken covered, Medicaid growth will be driven by; one, opportunities for managed care in states without Medicaid managed care; two, states with some form of managed care that Centene doesn't currently serve; and three, complex populations that we believe will make their way into managed care in our current footprint. Added to that would be an assumed low single-digit annual rate increase, slight market growth and market share growth in a post redetermination environment. Subtracted from that would be a practical view of potential market share reductions in a few of our states. Collectively, we get to a CAGR of 6% to 7% revenue growth in Medicaid. Marketplace is expected to grow at a mid- to high single-digit revenue CAGR based upon trend rate increases, rural and second-tier city penetration and our Marketplace chassis being a great solution for not just the uninsured and underinsured but also disrupting the employer group market. Though it may take a few years, we believe employers will be less and less likely to select their employees' health insurance plans over the long run. The Medicare Advantage individual market has been growing mid- to high-single digits for the past 5 years. We see this continuing for the foreseeable future. Once we get our Stars revenue to a reasonable level, when coupled with annual rate increases, we expect to be able to grow the Medicare revenue stream at a high single-digit to 10% CAGR. This also includes a little more geographic territory to cover over this time period. When you blend these businesses together, we believe we can drive a long-term CAGR of 7% to 8% organic revenue growth. Our #1 capital deployment priority just like today will be to fund the organic growth we just covered. This typically manifests itself in supporting new premium revenue with risk-based capital, but that won't use all of our free cash. We should be able to drive a 4% to 5% EPS CAGR through share repurchase, prudent debt management and creating debt capacity for future M&A. I love capital deployment and these are exciting times at Centene. Let me wrap this up. Centene is very well positioned in the growth part of managed care government programs. The government program's [indiscernible] is growing, and there's meaningful penetration opportunities to convert populations into managed care, especially in Medicare and Medicaid. We also have a hell of a chassis called marketplace that can be used in the long run as a disruptor to shape evolving market dynamics in both the uninsured and commercial group markets. There are continued opportunities to be more efficient and effective, which we will not only seize through the value creation plan in 2023 and 2024, but also over the long term. And we are attracting industry talent, unlike we've ever done before. This is the place to be in managed care. If you want to make a difference through business execution internally and serving the economically challenged and medically complex populations externally and enjoy working with a fantastic team while doing so. And you get all of this for an attractive 13x 2023 adjusted EPS or 11 to 12x 2024. We believe we can deliver a 12% to 15% adjusted EPS CAGR thereafter. And as you've seen, we've been a buyer of Centene, we would welcome you to join us. Thank you for your interest. Let me turn it back over to Sarah now.

All right, get your questions ready [indiscernible]. Coming out of 2022, hopefully, it's clear that Centene is an organization that has clear priorities and knows how to focus and execute. We are proving that we can operate more efficiently, grow more profitably and not just preserve but better reinforce our mission by creating value for our members and for our shareholders. Going forward, Centene will focus on what we do best. We will show up in the right way for our stakeholders and honor our commitments. We will demonstrate operational excellence and deliver high-quality experiences for our members and our providers. We will partner with the communities we serve to transform their health at the local level. This organization is more than 70,000 team members strong and 100% committed to the transformational mission of delivering dependable, high-quality, low-cost health care to our members and delivering value to those who have invested in this mission. Thank you for the time this morning. With that, I will turn it over to Jen for Q&A.

Okay. Without further ado, we'll go ahead and start the Q&A. We have folks with some questions. Great. I think first, we're going to go to A.J. Rice from Credit Suisse.

I guess, first of all, maybe just thinking through what you said about Medicaid, that maybe people are now using community health centers more to access primary care. I know a few years back, there was more discussion about people showing up in the emergency room among your customer base. Is that -- do you think that's a material change? Has that materially benefited you? And as you're talking in different markets, do you think that will reverse over time? Or is that something we'll just see that continue?

Yes. Thanks for the question. So we've definitely seen a suppression in ED utilization in non-emergent among adults in Medicaid. Pandemic, I think an obvious factor in that. But it has not reverted as quickly in the last 2 years. So the question has been [indiscernible] we've been asking ourselves and watching closely, is that a structural change or not. And I think I'll let Drew talk a little bit about some of the trends -- utilization trends that we're seeing, especially relative to a more normalized flu season. But I think relative to the potential for structural change what Brent and team talked about in terms of penetration in value-based contracts and value-based arrangements with some of those FQHCs, I think that is driving a different utilization pattern within the Medicaid population and one that we want to lean into.

Yes. I think what will be interesting is once we get through flu season to see -- because we've seen ER utilization, even non-emergent push up a little bit during the flu season. Do we revert back to that slightly suppressed level which then maybe we'll be able to make a judgment on whether that's structural or not. But there's a lot more connectivity, I think, post pandemic between our members and their physicians, the rise of telehealth has certainly helped that as well.

How much has the corridors that the states have implemented impacted that? I mean, is the underlying trend better than what we see, but it's getting held back a little bit by the corridors or has that pretty much worked its way through the system?

Yes. I mean, our corridor payable for this year is going to be around $1.8 billion. So yes, would be an answer to your question. Some of those are $300 million or $400 million, that is COVID era. The rest of it is sort of the -- even the pre-COVID profit mechanisms and corridors that are in place.

Great. Our next question is going to come from Josh Raskin of Nephron Research.

I appreciate all the commentary today. So 2 quick ones. The first, just on Stars and MA. Is there a reason -- I know you've got the 60% target. Is there a reasonable thought on first year 2025 -- first year of the 3 years, 2025? And then my real question is just if you could give a little more specifics on this value-based care initiative and this partnership model, how much of your membership is an actually full delegated, capitated arrangements? Because I'm not sure that was the percentage you guys were talking about. And is there a risk to competitors getting an advantage on the cost management side without ownership? Or do you think there'll be real payer-agnostic models that you guys can leverage?

I can take the first question. Sorry, Josh, I can't see you. So our goal over the next 3 cycles is to have at least 60% of members in for Star plans. The hope would be to have fairly ratable progress, but it's a little bit too early to see because, again, the metrics that are going to contribute to this next cycle [indiscernible] in 2022 that then trail into half of '23. So we need to get through cap. So too early on that front. But again, you heard from Sarah and there's a lot of work on the fundamental underpinnings. And then maybe, Brent, do you want to talk a little bit about the percentages that are in value-based arrangements and how we define that?

So value base would be, yes, capitation delegated risk and some gain share if you're asking, Josh, about true capitation delegated risk [indiscernible] it's roughly about -- in Medicaid, it's roughly about 35% of our membership there. And then for Medicare Advantage, again, correct me if I'm wrong here, roughly about same definition, delegated risk, capitation. So roughly about 35%.

Yes, I would say on Medicaid, it's 26% -- about 26% upside, downside, capitated and then the other 15-or-so percent in Medicaid is what we would call shared savings, which will be the upside only. The other thing I would say there, and it really applies to all the lines of businesses, there's a progression, right? You're -- over time, we're going to be moving and have been moving more providers to upside, downside. A lot of providers don't want to take downside risk initially because they're not used to working in a value-based kind of arrangement. As they get a comfort level, they tend to move more into the upside, downside and there's more of a willingness to take risk. Josh, to your -- another part of your question, in another life, 15 years or so ago, I participated in some of the acquisitions and building of some of the clinics that are in use today. We did that back then because as we looked at the playing field, there weren't a lot of qualified provider groups that could take risk. And so we felt like back then that it was important for us to create that capability internally. Recently, we've looked at our markets that we do business. I've got a 104-page document on my desk that takes all of our membership by line of business, maps it all out. And we inventoried all of the risk takers that are out there, and you all know a lot of them [indiscernible]. There's a significant opportunity to work with a lot of those folks in all the markets that we do business. I can't find a market where we couldn't have a relationship with some of those entities. Below those entities, there's a lot of companies that are starting to try to aggregate physicians who could move into value-based. So what we believe is that we want to partner with not only the top tier [indiscernible] but we also want to create enablement tools for those that are a layer below so that we can educate them on how value-based works and share with them a movement to population health and getting people into the doctor's office more timely as opposed to waiting for an acute event [indiscernible] RAF scores and the like.

That makes sense to follow up. You'd want to own the enablement component of that? Or you think you're going to rely on the aggregators [indiscernible]?

So no, I would like to own it for the middle tier and lower-tier physician groups [indiscernible] we spent some time with [indiscernible] about 2 months ago. They have all the tools that they need to do that. All we have to do is feed them the data. It's the MSOs that are aggregating and some of the doctors who have large panels, but haven't organized themselves yet. And we believe we need to be best-in-class at that.

And just to emphasize, the biggest it there is the data, right? And that's part of why we talk about harnessing our data and being able to fluidly bring that forward for providers.

Covered a lot of ground there. Our next question will come from Scott Fidel at Stephens.

I was hoping maybe you could give us a little more color on the 2023 MA annual enrollment period and the updated outlook for MA enrollment for the year. I think it's down a little bit from what you had been thinking about earlier the low single-digit growth and now looking for flat for the full year and dipping a bit of the AEP. You touched on some of the dynamics before. Maybe just give us a little more detail on a few of the other dynamics in terms of, clearly, you're looking for solid MLR improvement, so pricing may be a factor, but also maybe some of the distribution dynamics, particularly around the direct-to-consumer channel where I think you've had a lot of growth the last couple of years, and there's been some evolution in that area of the market, I think, for 2023.

Yes, absolutely. And you're right to point out that our major focus has been on margin improvement. So Medicare was the last into the value creation shoot, right? We started with Marketplace last year, taking that journey of margin expansion, fortifying the underlying operations. And the real focus coming into 2023 was to take Medicare on that same journey. But Ken, do you want to talk a little bit about the underlying dynamics?

Yes. Our proprietary channels have performed really, really well relative to the -- and we were -- we probably rotated a bit out of balance in the prior year's [indiscernible] kind of growth, also contributed some of the Star challenges and some of the other things you've noted. But our focus and long belief is that fixed cost, low cost, high productivity distribution, more control and create not only a better outcome with respect to new sales performance, but better persistency over time and a stickiness that I think will serve us well as we move to sort of balance -- we'll never be able to do that all alone. But we believe you need to own your distinctive competencies and distribution in the Medicare business and in our marketplace business, our distinctive competencies. And I would draw maybe as to correlate some of what you've seen in terms of the incredible growth we've had in marketplace. We have unmatched broker loyalty and deep, rich relationships with a producing universe. And if you know this space, they -- those brokers declare a major, right? So the folks that we're working with over there don't necessarily work in Medicaid. It's usually about -- if they're 80% Medicare, they're 20% Marketplace, and vice versa. But the attributes, and the --I mentioned earlier, the currency's exchange and the relationship we enjoy with physicians, the same theory applies. The currency we enjoy and the relationship we have with our producing partners is more than money. It's not really what they make. It's what they keep. And so when you look at tools, technology leads, lead management. And that's all gotten tough and vastly more challenging for a lot of the bigger names you know. And by virtue of that, there's been a little churning inside of those books. So the way to insulate ourselves from that is pick our partners carefully, invest in net and value-based relationships on that side and work to ensure that we have more proprietary channels and more control. And we see that as we layer -- as we look at our results [indiscernible] that those channels are outperforming the bigger names you might know. I teased earlier about being old. The one thing that I've learned in my time in this space is relationships are really important. And so we've been pushing to get more of our sales coming from our W2 sales reps as well as direct channels because they start to create a relationship with the senior that's really, really important. And all the things that we do thereafter with welcome calls, our clinicians reaching out to the folks that need it, relationships matter and the life that we keep those seniors extend significantly. Yes, Jim, that's a really important point, moving from a transaction to a relationship. Every successful sale through our control channels yields to referrals. So when you think about the investment we make in not only cost per sale, but lifetime customer value, that's why that's so powerful. And we're obviously on that journey as we speak.

Great. Our next question will come from Justin Lake of Wolfe Research.

A question on Medicare Advantage margins coming out of 2024. With the Star rating pressure you have there, I'm curious, can you give us an update of where you think those margins will sit in 2024? And then the -- how that compares to what you think the target would be once you get to that 60% Star rating?

Yes. So setting the table and sort of looking back, there wasn't much margin in the last couple of years, but there is crazy high growth. That's, quite frankly, what the company was focused on and that's how the bids were designed. And you step into this year, as you heard in my remarks, a little over 100 basis point improvement in the HBR and Medicare Advantage. We actually are doing a little bit better this year than we expected. So coupled that with another 100 basis points going into next year. We've thought about 2024 and the Star headwind that we knew and became more and more clear as we got through 2022 as we design the bids for 2023, so that we don't do anything that would be really disruptive for '24. Hence, going for margin versus enhancement of benefits. So we took a multiyear approach on the benefit plan designs for multiple years. We will be giving margin back in 2024. We sort of have modeled that. We planned for that. That's why we've got other levers that we've been working on the value creation plan. That's factored into our estimates for 2024. But we'll be giving margin back temporarily until we start ramping up Stars revenue again and executing on clinical initiatives and getting more efficient on SG&A and all the other things that the efforts that you heard about today will yield. So you really have to think about this and luckily, I was taught by very smart people that have done well in Medicare Advantage as well as these guys. It's -- you have to have like a 3- to 5-year game plan in Medicare Advantage.

So just as a follow-up, will Medicare Advantage be profitable in 2024?

Well, there's a few things we still don't know about '24. I don't know what the advance rate is going to be, the final rates. So I mean there's still some unknown components, how we exit the back half of '23 with run rate. So I will have to answer that when we get to 2024 guidance. But what we've modeled in is a pretty big hit due to the absence of Star revenue in '24, that's made up for by other levers. The good news is those other levers largely should persist into '25 and beyond. And then we can get that revenue back, and therefore, the earnings back in Medicare as we step into '25, '26 and '27.

Just lastly, what is the Medicare Advantage target margin, Drew, when you get to 60% Star ratings?

So if you look at our [indiscernible] net income margin of 3.3%, you back that up to a pretax number, it's 4.4% based on today's tax rate. And Medicare would be just above sort of running that zone just above that. Marketplace, 5% to 7.5%. And Medicaid, given the structural aspect of Medicaid would be a little bit below that margin target.

Great. Our next question will come from Cal Sternick at JPMorgan.

I wanted to ask about the Marketplace and the employer group opportunity you called out there. I know when the ACA was first being implemented, there was some thought that employers could move employees to the exchanges, but that never really materialized. So I guess the question is, one, why now? And two, I think I heard earlier, correct me if I'm wrong, but 89% of your members are subsidy eligible. If you think more employers are moving to this market, is there anything you have to change in terms of benefit design or provider networks in order to move further up market?

Yes. So let me hit on a couple of things that have changed. So -- and you heard some of this from John, right? So one is just overall stability. So we're no longer in a mode where there's a question of whether this is going to get repealed and replaced. On both sides of the aisle, people understand that this is here to stay. The enhanced APTCs being extended for 3 years only has added to that layer of stability. I think that's part of why you're seeing some of the overall market growth is that folks who are actually -- I think we thought were unreachable, I think have actually been more standing on the sidelines because they were unsure about how durable the product was going to be and the market was going to be in the long term. So that's a big factor. There are a couple of different market dynamics around the employer market broadly, which also sort of coalesce with the generation of shoppers. So think about a millennial generation that is used to shopping for everything. They want choice, they want customization, and the dynamics of a gig workforce that has ramped up significantly in the last 5 years where you marry up the desire to choose with the need to choose. And then on top of that, COVID, actually, I think, for a lot of those workers highlighted the need for health insurance because it was more of probably, especially for younger healthier workers [indiscernible] concept and then it became very, very real. So those are some of the factors that I think are bringing people into the marketplace. But relative to the why now, I think we would argue that it in some ways, it's already happened. It's just happening sort of under the covers. And I don't know, Ken, if you want to talk a little bit about these?

And not to challenge your premise certainly, but just to offer perhaps a slightly different way to think about it. So prior to the ACA, if you defined a small group, let's say, 2 to 9, right? Back when we were underwriting in that environment, that was some of our most profitable business, also paid agents 6% to 8% to write it. Over time, as that business transformed, if you followed those carriers, they don't want 2 to 5 and 7-like business anymore. They stop paying commissions on that book as it moved to guaranteed issue. And quietly, those lives started to migrate into the individual market. But the week before the ACA, 50% of -- if you think about the size of the small group market, at that time, 50% of the small groups didn't offer a qualified plan. The take-up rates inside of the groups that did was in the 70% range. So there was already, part of that universe that was in and out of individual coverage but the individual market was also an underwritten market. So 20% of the lives that would be submitted were turned away because they were rated up because they were otherwise uninsurable. Not all those people were low-income, right? So in fact, early in the ACA, they were some of the first people to migrate over where folks that would otherwise couldn't get coverage in the open market. And some of that pricing created some of the movement of big carriers in and out. As Brent mentioned, we're the only company that's really [indiscernible] stayed in there. So there has already been quietly to Sarah's point, a subtle movement of what was otherwise the traditional small group market in. And then ICRA, and as you think about the commercial market, it's not growing, right? So for one big broker to grow, another one has to shrink. And they're always looking for ways to create differentiation and to get themselves in. They're -- we're already starting to see in pockets where, to your point, depending on the nature of the comparison of the group rate to the individual rate -- take a market like Ohio, we're already seeing big brokers carve-out classes of employees and moving them into the market. So we had the benefit of getting just by virtue of our market share, we're getting some of that business that's beginning to move. What's in our R&D shop, is -- and we're asking ourselves the question, do we need to move from a market -- do we need to move from being just in the marketplace to being a marketplace, which implies maybe technology platform and other lines that are really intriguing. When you think about the brand loyalty that's been a byproduct of our stickiness, our broker loyalty, so it's consumer and broker loyalty. And you add perhaps even some growing price elasticity tied to that, which hasn't been historically part. But now I think you heard both from Jon Dinesman and through our presentation is a market that's vastly more stable I think those things worked to our advantage. So long answer is I think you're going to see that build up. It's going to be more geographic and it's off to Sarah's point, it's already subtly been happening. If you connect a quick dot, we talked a little bit about proprietary sales channels in Medicare. Having the ability to have those folks selling product for us could transfer into the marketplace and other kinds of individual products.

Just a quick follow-up. You said this has been going on for some time already. I mean -- I guess, are you thinking this is going to really expand materially going forward? And how should we think about the magnitude of it within that mid- to upper single-digit CAGR you gave?

Yes, the mid- to high-single digit doesn't contemplate a quantum shift, but we think that's possible, and that's why it's in our R&D shop to make that market happen, but it doesn't need to happen to achieve the mid- to high-single digit.

Great. Our next question will come from Michael Ha, Morgan Stanley.

So just to come back on MA Stars. I know 20% is a target for '25. Just curious, what gives you confidence and visibility on reaching that? I know on the technology side [indiscernible] that's AI-driven for risk adjustment. But do you have anything that has real-time tracking for Stars that gives you confidence that 20% is achievable? And also, I think CMS has a dynamic where they provide updated cut points for measurement data later in the year. Do your estimates also include an estimate on updated measurement tough points?

That lady over there has used a bunch of folks to construct the kind of information that you just asked about. We are -- on a weekly basis, we look at where we're tracking towards and what we need to do to improve. Things that we're in the middle right now of going out to doctors' offices and trying to get gaps in care closed so that our HEDIS scores are going up. We kicked off the other day in a town hall, a large effort around CAPS. CAPS is going to be measured from March to May. So we know exactly where we're at -- and we've -- Sarah has given me scenarios that said, if CAPS can go from blank to blank [indiscernible] possible, so we feel pretty good that we should be able to get that 20%, then 20% the following year and then 20% the next.

Great. I'm going to enact moderator privilege and take one from the web. So this question comes from Dave [indiscernible] Jefferies. It's a question about marketplace and he's asking how do the value and virtual access in some of the newer products that we've introduced into the Marketplace market, how are those performing? And as you think about '23 enrollment, how has the uptake been there?

Yes. Brent, do you want to talk a little bit about that?

Yes. As far as performing in regards to the population, doing very well. And as far as people selecting as we're going through our [indiscernible] right now, also very well. Obviously, we've expanded our virtual this year. So we put -- we have more states and so forth. We had a nice beginning learning from it from '22 as moving into '23, we'll be in more states. And -- yes, we're seeing more people continue to go to that. They like that you have the ability to go online and be able to have telehealth. At the same time, if you still want to go to a physician face-to-face, you have that, you just pay the co-pay. In regards to more of our clinic model, which we're doing in South Florida and expanding and doing some of this in Texas, we have great experience with it right now in '22 and continue to grow that into '23 from that standpoint. And then more tailored networks approaches that we're doing, absolutely is helping us be very competitive from these standpoint. So pricing is helping competitive. And we're really finding that the members are selected. But I do want to be clear, though, our core network is still the predominant of what people are selecting.

Great. We'll come back to the room for the next question from Steve Baxter, Wells Fargo.

I was hoping you could talk a little bit more about how you're thinking about Medicaid market share inside your long-term guidance, a little bit more maybe on those pragmatic assumptions and what they look like potentially using the upcoming Florida RFP as an example, and what a good outcome looks like there? And then to that point, can you just talk a little bit more about how you're continuing to innovate in the RFP process to defend and expand your market share?

Yes, absolutely. Maybe I can hit the first point, and Dave, you can pick up on some of the RFP innovation. So when we think about the pipeline going forward, we obviously have a number of big states that are ahead of us in that process. And as Drew said, we take a very practical approach. And because we are on the ground and local in those states, understand what the shifting dynamics might be in terms of what the construct of the RFP will be. And so we use that to inform our projections and to bake that into all of the assumptions that you've seen. So Florida, we have a little over 2 million members, I think. So it's obviously a bigger state for us. It's a state where when we brought Centene and WellCare together, we actually anticipated they would require us to shed some of our market share. And instead, the viewpoint was that competition is good, and if you are a strong competitor that you should have the market share that you have the right to earn. And so our goal, as we've been preparing for the RFP process is to make sure that we have performed well and built the strongest possible relationship. But we're also practical about the idea that we have a pretty heavy market share there, and we take those puts and takes in addition to the fact that there are States like Nevada, for example, where we started with a much lower membership. There is same-store growth opportunity in a number of different markets. We bake all of that into the projections. And then on RFP innovation?

Yes. We are seeing a lot of states looking for innovation from the respondent to the RFPs. And a lot of that, if not most of that, is in the areas of drivers of health, social determinants of health, health equity. And we feel like we're very well situated there. And just maybe a little bit on what that actually means. Those are things like food and security, lack of housing, lack of access to transportation, those kinds of things. So we're having to build all of that into the RFPs, tell the states what we plan to do. There are some states that are even requiring that we have specific positions within the plan that just are strictly focused on that. So we are, I think, where we need to be in terms of making sure that we're building all of that into the RFPs. We did that very successfully in North Carolina, which I think was one of the earlier states that really put a lot of that innovation stuff in there. And we, as you know, did very well there. So very focused on that and very focused on making sure that once we put something in an RFP, we implemented that we're actually delivering on those promises, and we're actually hooking people up with those services and making sure they have access.

Plus, there are a lof of new opportunities. One, you see up on the screen, we were talking about LTSS and Indiana RFP, new opportunities in new states that are going to manage care like Oklahoma. And of course, don't forget, Oklahoma also had Medicaid expansion. And they also have a separate RFP for foster care. And you're seeing a lot of states move forward to sole-sourced foster care, which are large parts. So we're really seeing states coming out of the pandemic and saying, well, should we add higher [indiscernible] population in managed care? Should we look at foster care? What should we look at? So there's a lot of new opportunity ahead.

Well, I think if you combine those points, it's also interesting because of our experience, for example, in LTSS, we have the ability to help states sort of define what innovation looks like, as we are going through the response for the Indiana RFP, our Pennsylvania team went to Indiana and was on the ground with them, talking to the team in Texas, and bringing all the ideas that are already in play around the country and baking that in so that each cycle, we get better and better in terms of what we're showing up with.

Great. I was going to say, we [indiscernible] already. But now I see Nathan Rich over there from Goldman Sachs.

Great. I wanted to ask a question on marketplace. The revenue growth for the segment seemed a little bit lower than what we would have expected given the membership growth. So could you maybe dig into that dynamic there just in terms of the composition of the membership growth for '23? And then sort of relatedly, it sounds like you expect margin expansion in 2023. Where do you expect to be within that 5% to 7.5% target that you have for the segment?

Yes, I couldn't be more pleased with the -- this year's performance of marketplace, as I said in my remarks, improved HBR over 500 basis points, which is, I think, remarkable. Yes, we had some -- we had a tough year in 2021 as a comparison point, but real good progress and not just pricing and execution. But as Ken mentioned, elasticity, as Dave mentioned, clinical initiatives, so we get that sort of run rate benefit. Going into '23, we price to actually get into that 5% to 7.5% margin. So we're stepping into that, which tells you in '21, we were actually below zero. So there's expansion, there's margin expansion through pricing but more -- just as much execution. And then on the revenue side, we've got $2 billion in commercial. There's a little bit of a slight headwind in the Commercial group business, not meaningful, but that's holding back that $2 billion a little bit. And then we're trying to predict sort of the yield of what's going to manifest itself through the open enrollment process, the yield of some of the products, the new innovative products have a little bit lower yield than the average of the portfolio. So that open enrollment is still going on. I think through mid-January. So we hope to get those members effectuated and then give you an update probably by early February on how open enrollment ended.

And if I could just ask a quick follow-up. It sounds like you still expect to recapture a few hundred thousand members on your marketplace plans as the redetermination process progresses. Can you maybe just talk about the conversations you've had with the states? It seems like there may be a greater focus on continuity of coverage, maybe your ability to capture more of those members in the Marketplace?

Yes. So every time the can gets kicked, right, we continue to have conversations with each one of our state partners and have done all the work. We've seen great progress in terms of willingness to partner, and actually some flexibility even potentially at the federal level in terms of our being able to reach out directly to members. So we still feel really good having 25 -- our footprint, 25 of 29 states with market overlap between Medicaid and Marketplace. But we still need to see, I think, how -- when redeterminations actually start, right? And then what that data looks like in terms of how many members really fall into the marketplace versus falling into group insurance or into the donut hole.

Great. Our last question for this morning will come from Ann Hynes at Mizuho.

I think in your comments, you talked about you were open to bolt-on M&A again. Maybe just talk about what type of assets you're looking for?

Yes. I'll take this, but others can weigh in and Jim has clearly got an opinion, too. So our main focus is we talk the field today in terms of core business. right? So that equates to looking at health plans that would grow our core Medicaid marketplace or Medicare business. And so that might be a way to enter new markets and may be a way to expand in existing markets. I think we are open to the idea that there may be acquisitions out there that, again, sort of amplify a core competency. But it needs to be something that we really feel like we need to own and that by owning it, we're not going to hurt the asset over the long term. So majority focus would be on core health plan, but keeping our eye out on some of those interesting capabilities that I think would allow us to differentiate for some of these outside market movements that we're talking about.

Great. Well, with that, we'd like to thank everyone for joining us this morning, and wish you and those closest to you a happy holiday season. If folks have any follow-up questions, you know where to find us. Thanks again.