Earnings Call Transcript - ALHC Q4 FY2025

John Kao, CEO

Good afternoon, and welcome to Alignment Healthcare's fourth quarter 2025 earnings conference call and webcast. All participants will be in a listen-only mode. After instructions after today's presentation, there will be an opportunity to ask questions. Operator instructions, please note that this event is being recorded. Leading today's call is John Cale, founder and CEO, and Jim Head, chief financial officer. Before we begin, we would like to remind you that certain statements made during this call will be FOIL-looking statements as defined by the Private Securities Litigation Reform Act. These FOIL-looking statements are subject to various risks and uncertainties and reflect our current expectations based on our beliefs, assumptions, and information currently available to us. Descriptions of some of the factors that could cause actual results to differ materially from these four liquid statements are discussed in more detail in our filings with the SEC, including the risk factors, sections of our annual report on Form 10-K for the fiscal year ended December the 31st, 2025. Although we believe our expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. In addition, please note that the company will be discussing certain non-GAAP financial measures that we believe are important in evaluating performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliations of historical non-GAAP financial measures can be found in the press release that is posted on our company's website and in our form 10K for the fiscal year ended, the sum of the 31st, 2025. I would now like to hand the conference over to John Kayo, founder and CEO.

James M. Head, CFO

You may begin. Hello, and thank you for joining us on our fourth quarter earnings conference call. For the fourth quarter 2025, health plan membership of $236,300 represented year-over-year membership growth of approximately 25 percent this supported total revenue of 1 billion dollars which grew 44 year over year during the fourth quarter we also exceeded the high end of guidance across each of our profitability metrics adjusted gross profit of 125 million represented an adjusted MBR of 87.7%. Meanwhile, adjusted EBITDA of $11 million solidly surpassed our guidance range of negative $9 million to negative $1 million. For the full year, total revenue of $3.9 billion grew 46% year-over-year. Adjusted gross profit of $495 million resulted in an MBR of 87.5%, representing an improvement of 130 basis points year over year. Taken together, this year marks a tremendous milestone in the maturation of our company's profitability. We transformed from roughly break-even, just $1 million in adjusted EBITDA in 2024, to delivering adjusted EBITDA of $110 million in 2025. This reflects an adjusted EBITDA margin of 2.8% and represents 270 basis points of margin expansion year-over-year. Throughout the course of 2025, we have demonstrated both the strategic and operational advantages of our clinically-centric model, which is purpose-built to deliver the highest quality care at the lowest cost. The data insights provided by our AVA technology platform, combined with our Care Anywhere clinical model provided us with the visibility and control necessary to navigate a year of significant disruption where we overcame the second phase end of the v28 risk model a redesign of the part d program and broad utilization pressures across the medicare advantage industry and importantly this allowed us to pursue growth while expanding margins even as competitors took a step back in 2025. i'd like to congratulate our team for their success and recognition by Fortune Magazine for their unwavering commitment to seniors, which named us to its world's most admired companies list for the first time. We believe our model of lowering costs by delivering more care to seniors, not less, is the MA model of the future, and we're eager to serve more seniors as we continue along our path towards a million members. 2025 also marked an important step in demonstrating the replicability of our model beyond California. We more than doubled our ex-California membership while consistently exceeding our financial expectations throughout the course of the year. As of December 2025, we had approximately 38,000 members across our markets outside of California, representing approximately 16 percent of our total membership we have grown confidently outside of california by first leading with quality which starts with success and star ratings we now have a five-star plan in north carolina for the third consecutive year two five-star plans in nevada a four and a half star plan in texas and a four-star plan in arizona these achievements are further supported by the portability of our Care Anywhere clinical model, which focuses on delivering care to our high-risk polychronic members. By leveraging the strength of our care model, quality of clinical outcomes, and scalability of our health plan operations, we are unlocking the growth potential within these markets. We are now focused on sustaining the momentum of our ex-California markets. In 2026, we plan to invest in our sales and distribution engine, build deeper relationships with our broker partners, and continue growing with aligned provider partners where we have durable relationships. With less than 4% market share across our 23 counties outside of California, we see significant opportunity to take share over the coming years. Turning to our 2026 AEP results, we grew to 275,300 health plan members in January of 2026, representing 31% growth year over year. We saw broad growth across each of our markets with 23% growth in California and more than 80 percent growth in our ex-california counties importantly we focused on growing responsibly through our bid design and sales strategy we drove nearly 20 improvement to our aep voluntary disenrollment metric and sourced approximately 80 percent of our growth sales from plan switchers by taking a balanced approach to growth and profitability this year we remain mindful of the impact of the final phase in of D28 while still capitalizing on the growth opportunity in a year of significant disruption. Taken together, we are pleased with the solid growth in California while continuing our rapid expansion outside of California. Our growth this year is adding to our future embedded earnings potential while supporting our near-term operating leverage objectives. Meanwhile, improved operating efficiency across the enterprise is creating additional capacity to reinvest in long-term projects and scalability initiatives. Each of these factors is giving us confidence in our initial full-year adjusted EBITDA guidance range of $133 million to $163 million. This is consistent with our previous expectations for consensus-adjusted EBITDA of approximately $145 million to be in the range of our initial 2026 outlook. Jim will expand further on our financial outlook in his remarks. Looking beyond 2026, I'd like to spend a few minutes on the 2027 advance rate notice. On a net basis, the announcement appeared to indicate a relatively flat rate environment for the industry. This reflected a combination of underlying cost trends and policy changes. While we have heard disappointment across the industry, we believe the update is largely consistent with the CMS focus on program integrity and aligning payments with underlying costs. Specifically, we are encouraged that benchmark trends reflect continuing growth in costs within the fee-for-service population. This was partially offset by certain policy adjustments, including those related to skin substitutes. As it relates to unlinked chart reviews, we have long supported excluding these records from risk score calculations as part of improving program integrity. Of note, our exposure is limited. Approximately 1% of our total HCC value is derived from chart reviews of any kind. Within that category, an even smaller subset is related to unlinked chart reviews. For those, we believe we have a clear path to ensuring the diagnoses are supported by a linked claim or encounter over time. Most importantly, the current environment reinforces the importance of our strong clinically led model and core medical cost management competency we believe this enables us to win in any rate environment just as we have demonstrated in 2024 and 2025 where the industry experienced tighter reimbursement and furthermore we will continue to have stars payment advantages in 2027 with 100% of our members and plans rated four stars or above. In closing, we believe we are entering a reimbursement environment that creates a more level playing field with our competitors, which allows our distinct care management model to shine. We are proving the effectiveness of our distinct medical cost advantages with the results we have shared with you over the past two years. While we're pleased with our performance, we're not done yet. 2026 will be a year of continuous improvement where we plan to make targeted investments across our clinical model, new market playbook, and scalability initiatives, including investment in AI workflows to improve administrative efficiency. In doing so, we are balancing our near-term financial objectives with unlocking the embedded potential of our model. that, I'll turn the call over to Jim to further discuss our financial results and outlook. Jim?

Speaker 10

Thanks, John. I will jump right in with our 2025 results. So, the year-ending December 2025, health plan membership of 236,300 increased 25% year-over-year. Growth in membership drove total revenue to $3.9 billion for full year 2025, representing 46% growth year-over-year. Full-year adjusted gross profit of $495 million represented an MBR of 87.5%, an improvement of 130 basis points year-over-year. We ended the year with strong outcomes across all major cost categories. Of note, Part D profitability and supplemental expenses trended in line with our guidance expectations. Meanwhile, our proactive care approach again delivered strong outcomes leading to inpatient admissions per thousand in the low 140s during the fourth quarter. Taken together, the strength of our performance across each of these medical cost categories and the durability of our clinical model are giving us confidence in our underlying bid assumptions as we step into 2026. Moving to operating expenses, our operating cost ratios continue to demonstrate significant year-over-year improvement as our operational infrastructure scaled to support our new members. Full year 2025 GAAP SG&A was $443 million. Our adjusted SG&A was $385 million, an increase of 28% year-over-year. Adjusted SG&A is a percentage of revenue declined from 11.1% in 2024 to 9.7% in 2025, representing an improvement of approximately 140 basis points. Taken together, we delivered full-year adjusted EBITDA of $110 million and an adjusted EBITDA margin of 2.8%. This represents 270 basis points of margin expansion year over year. Turning to cash flow in our balance sheet, we generated positive free cash flow in 2025 and ended the year with $604 million in cash and investments. Subsequent to the quarter, today we announced the close of a $200 million revolving credit facility. This facility is simply good housekeeping and further evidence of the maturation of our capital structure. We do not expect to draw on the credit facility in the near term, and our increasing positive free cash flow position allows us to support our organic growth objectives. Moving to our guidance. For the full year 2026, we expect health plan membership to be between 292,000 and 298,000 members, revenue to be in the range of $5.14 billion to $5.19 billion, adjusted gross profit to be between $615 million and $650 million, and adjusted EBITDA to be in the range of $133 million to $163 million. For the first quarter, we expect health plan membership to be between 281,000 and 285,000 members, revenue to be in the range of $1.21 billion to $1.23 billion, adjusted gross profit to be between $138 million and $148 million, and adjusted EBITDA to be between $26 million and $36 million. As it pertains to our full-year expectations, given the strength of our OEP results and continued stability with our retention, we are raising our year-end membership guidance by 2,000 members at the midpoint relative to the commentary we provided in our January 8K. Moving to revenue, the midpoint of our initial revenue guidance range of $5.16 billion represents 31% growth year-over-year. The expected year-over-year increase to our revenue is primarily driven by our membership outlook. Meanwhile, our underlying revenue PMPM assumptions are balanced by increases to benchmark rates and the Part D direct subsidy. This is partially offset by the impact of the final phase-in of B28 risk model changes and mix of growth outside of California, which carries modestly lower per-member revenue. Turning to adjusted gross profit, our $633 million guidance midpoint implies an MBR of 87.7%. The outlook contemplates improvement from the retention of existing members and modifications to our product designs within markets to reflect the current reimbursement environment. These tailwinds are balanced by the third phase in of V28 and our new member mix, which is disproportionately represented by LIS, dual eligible, and CSNIP eligible members. Caring for these complex members is core to our clinical model, but they typically join with higher MBRs in year one as we transition them from an unmanaged setting to our care Additionally, as a reminder, we do not incorporate any assumption for sweep pickup from new members in our initial 2026 guidance. In 2025, this pickup was a benefit of approximately $14 million to our full-year adjusted gross profit and e to dot or roughly 30 basis points to our consolidated mbr moving to sgna we forecast further improvement in our sgna expense ratio we expect to achieve operating expense scale economies resulting from both membership growth and enhancements to administrative workflows as john mentioned earlier we also plan to reinvest a portion of the savings derived from improved operating efficiency towards further advancements in our clinical model, new market activities, and technology infrastructure to prepare for scaling our business and the deployment of AI workflows in the future. Taken together, we expect to deliver adjusted EBITDA of $133 to $163 million, consistent with our preliminary profitability comments provided earlier this year. Turning to our seasonality expectations, we expect a modestly lower MBR in the first half of the year compared to the full year average. Conversely, we expect the second half of the year to be slightly higher versus the full year average. Our initial view generally reflects the regular seasonality of our Part C MBR experience combined with a flatter slope to our Part D MBR in 2026. In conclusion, the 2025 execution of our clinical model, the replicability of our results across markets, and the consistency of our operating performance all give us tremendous confidence as we enter 2026. We are excited for the significant growth opportunity in the years ahead and are determined to make the right investments in people, processes, and technology to ensure that we are scaling responsibly. With that, let's open the call to questions.

John Kao, CEO

Thank you. Ladies and gentlemen, to ask the question, please press star 11 on your telephone, then wait for your name to be announced. To withdraw your question, please press start 1-1 again. Please stand by while we compile the Q&A roster. Our first question comes from the line of Michael Hall with Baird. Your line is open.

Michael Hall, Analyst — Baird

Hi, thank you. So I want to frame this question by calling out a few numbers first. So over the past two years, alignment has seen nearly 50% revenue growth kicker, I think almost 500 basis points of margin improvement, right, sub-10% GNA, all while improving to 100% of members in four-plus star rated plans. And all of this happened in a flat rate environment while trends nationally rose to high single digits. So on the heels of all of this, and with the potential again for another flat rate year in 27, my question is, I guess simply put, what would prevent alignment in 27 from having a rerun of what you just accomplished in 24 or 25? because it looks very similar, the setup into 27.

James M. Head, CFO

Well, Michael, this is John. You should probably expect my response to be, you feel very comfortable with a 20% growth rate. No, we feel good. I mean, the model is working, and it will work irrespective of what happens in the rate universe. You know, and I think that if rates do go back up a little bit in terms of the advance switching to the final notice, I think it'll be fine. I think what I'm hearing in terms of the amount of potential increase is still going to be pretty short of what we think trend is, at least what the sector thinks trend is. So I think that will be something favorable to us. And if rates don't go up, I think it could be more favorable to us. And I think we're going to do exactly what we've done year after year, which is be very, very disciplined and find the right balance between growth and margin expansion. I would say that we don't want to get ahead of our skis on terms of growth. We don't want to talk about bids. I do expect, and I said this to people beforehand, I think it's still going to be one or two years of, you know, kind of people, you know, finding the right model to dig out of this kind of post V28 world. and I think that there are some folks that grew a lot this past year for AEP and we chose not to grow at the level some of these other folks grew. We didn't just grow to get growth. We wanted durable provider relationships. uh we wanted to make sure our infrastructure would you know be able to sustain you know the level of stars that we've been able to produce um and the other thing that we're doing is we we you know we we know how good we're doing in 25 and i feel very strongly about 26 as well We're taking the opportunity and we're not complacent. We're getting even tougher on ourselves internally from an operational perspective, from a clinical perspective, from an AI deployment perspective. We're just getting stronger to really get to the level of growth we think we can get to over the next three or four years, you know, getting to a number of growth that will be really meaningful for everybody. That's kind of how we're thinking about it. So, Michael, I mean, you called it two years ago. So I'm not going to give you the benefit of calling it again quite yet.

Michael Hall, Analyst — Baird

Got it. Helpful. Thank you so much, Sean. Okay, my next question, the implied MLR for 26, Jim, I think you mentioned midpoint 87.7. If I were to trip out that sweet payment from 25, I'm seeing maybe 10 bps of MLR improvement year to year. So, at first glance, it feels a bit conservative since, like, fairly prior years, you've grown a lot more and done a lot more MLR improvement. So, I'm just trying to understand the assumptions embedded in MLR a little bit better. I know you mentioned LIS, CSNIP, E-SMIC, member mix. How much does that year one member mix impact your year-to-year MLR? What are you assuming on trend in 26 versus 25? Just a general sense on the various components.

Speaker 10

Yeah, and thanks, Michael. I guess a couple things. Just in terms of the inputs to the 2026 guide, I mean, there's kind of three core inputs that we feel pretty good about. So I want to start with that. And our 2025 experience, how we've managed cost and delivered throughout the year, new members delivering, et cetera, you know, that gives us a lot of confidence as we go into the year. We also bid in mid-25 for 2026. And you say, okay, how do we feel about that now that we're in January, February? and building our models for the year. And it played out very, very nicely in terms of how we thought it was going to happen and happen. And then finally, John's point. This is very disciplined growth. And we chose to play in spots where we could win with the products we like, with the cohort of members that we like, and the geographies and the networks that we like. So that's the setup. Now, as it pertains to the NBR, you're right, it's about a 10% kind of apples to apples improvement because, or 10 basis point, I should say, apples to apples improvement because we're stripping out the impact of the suites last year. I would say three drivers, Michael, that, you know, kind of are inputs to why it wouldn't be better. Number one, we're still going through the third phase in a B28. Okay. And so we've navigated that very, very nicely, as you mentioned, but that's, that's, you know, that does, you know, it's not a tailwind. It's a, it's a headwind. The new member mix was disproportionately represented by dual eligible, CESA eligible and LIS members, which is our sweet spot, but they come with a little higher NBR in the beginning. So it is, that is a little bit of a headwind, but the trade-off is we know how to manage these members really well. And there's a lot of long-term opportunity there. So we consciously made that choice. And it was a big portion of our AEP. And then, as I mentioned before, we didn't have a suite. So I think the V28 and the new members coming in at that, I'll call it, you know, a heavier mix in terms of special needs, et cetera, is driving that. But we feel very good about where we're at with respect to the visibility we have. And I'll also throw in Part D. A second year, we did a great job delivering on Part D in 2025 and, you know, on our promises. And we have a fair degree of visibility as we go into 2026. So I'd say that was another input that was part of the overall mix. Perfect. Thank you so much.

John Kao, CEO

Thank you. Our next question comes from the line of John Stansel with J.P. Morgan. Your line is

John Paul Stansel, Analyst — J.P. Morgan

open. Great. Thank you for taking the question. I know you called out potentially changing some approaches around your distribution network and broker community. You talk about how you're thinking about that change. And then maybe looking at the 27 commentary a little bit, I think there's been an expectation about essentially expanding into new states in 27. Is that indexed at all to needing a better rate in 27, or is that something that you think you can do in an all-weather environment?

James M. Head, CFO

No. Hey, John. It's John. Yeah, with respect to distribution, you know, we're going to – and I think that comment was specifically related to some of the ex-California markets, including some of the potential new market entry strategies that we're going to be taking into existing states, new markets in existing states, and what we're doing with potentially getting into another state. And so we're at a size now in pretty much each of our markets that we're really kind of a player and relevant. And so I think we've got deeper relationships with brokers and providers. and a lot of the success that we've been able to achieve in California is starting to take root in these new markets and that really does start with the providers and and what we've learned also is really is the brokers are really pretty pretty important in that that discussion and you put that against the backdrop where the receptivity of the brokers is just much greater given the fact that a lot of the incumbents are taking a step back for the last year or two and maybe for the next year or two. I think that creates an opportunity for us. And so we're just very intentional about that. With respect to new markets, we are seriously thinking about that. We're not quite where I want to be quite yet with some of the provider engagement conversations, conversations but I'm pretty comfortable we're going to be able to get into a new state and the the rates I just don't think that matters to us I think I think it's going to be whatever it is it is and I think we're going to do well in any environment I really mean that and again a lot of this is choosing the right provider partners, which I think we have in these two distinct new markets.

John Paul Stansel, Analyst — J.P. Morgan

Great. And then on the RFI from CMS that is still out and about, but has received comments at this point, a couple of different topics embedded in there. As you've had further discussions with the administration and with your counterparties, how are you thinking about potential incremental

James M. Head, CFO

changes that could potentially come out of out of that RFI uh tbd i mean we we submitted our comments like everybody else yesterday um you know i i think from a policy point of view you know i i think we'll see what they have to say around the reward factors and the hgi um again we'll see what happens i think we're going to be okay either way And I think from a kind of just more information gathering purposes, we feel pretty strongly about kind of the C-SNPs remaining as C-SNPs and not really getting linked to any kind of aligned network. And, you know, the logic there really is we want there to be choice for the beneficiaries. We don't think that's right that the beneficiary should be forced into, you know, a suboptimal star rating plan who's more of a Cade plan. I think they should really be, you know, have choice, get the right benefits, get the right network, and just get the right quality they deserve. But other than that, you know, there's other moving parts. I've been asked, you know, what do we think about risk adjustment going forward? You know, we do support documentation of the HRAs. We've always supported that. So I think that's a good thing. I think the administration focusing on program integrity and minimizing gaming, all that is kind of the right direction. but as I mentioned earlier I do think there's going to be some exposure on rates as the previous Mike said before I think we stand to be a beneficiary of that but I think they're going to do the right thing on rates that's what I actually think when the final comes out. Thank you. Please stand by for our next question.

John Kao, CEO

Our next question comes from the line of Matthew Gilmore with Key Binds. Your line is open.

Matthew Gilmore, Analyst — KeyBanc

Hey, thanks for the question. I wanted to start off with the ADK metric in your outlook. Can you provide some more details and unpack what drove the favorability in the fourth quarter? And then also, as we're looking ahead, I would think the ADK metric will probably tick up given the duals mix, but just wanted to get a sense for what's the right kind of apples-to-apples comp for ADK that's embedded within the guide.

Speaker 10

Well, I'll start with how we finished the year. We had an expectation, if you remember, in third quarter, Matt, that ADK might tick up. We weren't ready to bet on flu season being favorable, and it did come in pretty well. So we ended the year, as we said, in the low 140s. As we go into the new year, the answer is yes, because of mix, our ADK could pick up a little bit. And that is not because the trend is wrong on an apples for apples basis, it's because of that. And so I view that as another component of the, I'll call it the cost trend that we're pretty maniacally focused on and managing actively. But it might pick up a little bit over the course of the year. As you're aware, first quarter is usually a little bit higher. So that's just a seasonal issue.

Matthew Gilmore, Analyst — KeyBanc

Great. Very helpful. And then, you know, maybe asking about AI investments. You know, you mentioned some investments in the prepared remarks. I think last call you also talked about AI within Care Anywhere and AVA. Just wanted to get a flavor for where some of the technology enhancements you have in flight, where they may be directed and how that may benefit the business over time.

James M. Head, CFO

Thanks. Yeah. Hey, Matt. It's John. Yeah, it's a great question. We've got 30 some odd different potential use cases where we could deploy agentic AI. Having the use cases is not our issue. What we're actually doing is to require two foundational actions be at a level where we're satisfied. And the first one is really as part of this kind of revalidation of everything. It starts with a unified data architecture. It starts with AVA. And we're just looking at everything. We're making sure all the data ingestion is as tight as we think it is. We're validating everything. We're not assuming anything, all of which is designed to ensure that we can scale and replicate without any abrasion. We're going to be just that much more efficient scaling. And what that really translates into is we're going to get to cash flow break even faster than we would have thought before. And we're going to grow and be more aggressive on stars and benefits as even more so than we did before. The second issue is what we're talking about internally is just making sure the end-to-end workflows within each functional area is well documented and, frankly, well understood. And what I mean by that is when you basically double in size every two years, you're bringing in a lot of people, a lot of new people that have to get trained. and so the training opportunity is to make sure that all of these different workflows are understood by everybody and then within the end-to-end workflows you've got micro workflows do you really know what's happening and then ultimately is the cross-functional workflow processes and when you again those are those are very sophisticated workflows that factor in our clinical work processes, our provider contracting work processes, which one of these providers are we delegating, are we not delegating, we have our directly contracted networks. All of that is being evaluated right now. And once I get those done, which we expect to have done mid-year this year, you're going to see us start deploying these use cases for agentic AI. The other thing we're doing is we're kind of revisiting the initial stratification model within AVA and I think there's going to be tools that we have sorry sorry about that I went on mute for a second I was going to say we talk about AVA and we're looking at using the new tools to make the stratification model even better for our Care Anywhere members as the 10% of the population we think that account for 78 percent of the spend um you're also going to see us uh have use cases around administrative improvements i think member services is going to be one of the first ones and i think there's going to be immediate savings there i think in our financial reporting i think you're going to you know we're going to be able to use ai and look at the raw data and be able to come up with actionable conclusions market by market i think those are things you're going to What we're probably not going to do is kind of lead the market in deploying agentic AI in care delivery. We're going to still rely on our doctors and nurses to do that. Hope that helps. It does. Thank you.

John Kao, CEO

Thank you. Our next question comes from the line of Scott Fidel with Goldman Sachs. Your line is open.

Sam, Analyst — Goldman Sachs

Hi, this is Sam on for Scott Fidel. I was just wondering if you could talk about just are you concerned about the MA industry that may have lost too much bipartisan support in Washington? And what can the industry do to improve its standing and position itself better to alleviate the ongoing regulatory pressures on the sector?

James M. Head, CFO

I think it's to get back to what CMS originally intended MA to be. And I think all the actions that I see going on are exactly consistent with that. Meaning, and I've spoken about this, they want a program that creates a value to the end beneficiary. And to define that, you've got to have higher quality, better experience. And I think to do that in a way that is the most affordable. And so this is what I always say. You've got to have high quality and low cost. And in that environment, the folks that can create the highest degree of value ought to be positioned to win. I think there's been some financial engineering away from that over the past several years, where there's an emphasis on coding, global capitation, you know, prior auth, all of which I don't think are going to be sustainable going forward. So I think if people just do what CMS intended them to do, they're going to be in a good place, you know. And I think the, you know, the benefit differential of MA relative to traditional medicare i think is going to cause ma to continue to grow not go down that's what i think uh and i think for the last 40 years we go through these different you know phases of whether it's the bba and the 90s and the aca and the early 2000s i mean you go through those peaks and valleys, MA has always thrived. It has always come through. And I just think it's I would be very surprised if that trend changed, put it that way. Thank you. Our next question comes from

John Kao, CEO

the line of Craig Jones with Bank of America. Your line is open.

Craig Jones, Analyst — Bank of America

Great. Thank you. So I wanted to follow up on what you said about the final rate notice for 27. You said you think CMS will do the right thing on rates the final notice we saw united in its letter to cms around the advanced rate notice thinks that growth rate for 27 should be closer to nine to ten percent versus the five percent in the advanced notice so where do you think that growth rate should be and then what do you think you know cms will actually end up doing when you say do the right thing thank you i think the i think the

James M. Head, CFO

thing that i've been reading about really is related to the the you know the impact of these skin substitutes and how that's been an effective offset to the utilization trends for traditional Medicare. And I think it remains to be seen how they actually manage that specific issue. I'm not sure it'll get up to the 9%, 10% rate net, but I think it's possible you get to the 5%. and I'm not sure that's still enough frankly to kind of fully meet the trend but I've got to tell you I was surprised by the rate notice and the advanced notice and very practically it was related to the midterms that's really how I was thinking about it and I think there's an opportunity with additional data that's going to be coming in to capture the second-half trends. I think they're going to come up with something, hopefully, to deal with skin substitutes that was a material takeaway. And I think it'll be something that'll be reasonable. Maybe I should say I'm hoping it'll be something reasonable, because if it's not, I think you're going to get a lot of people that are going to degrade benefits even more. And it is a real issue. And we saw this during BBA, you know, 30 years ago.

John Kao, CEO

Our next question comes from the line of Ryan Langston with TV Colors. Your line is open.

Ryan Langston, Analyst — TD Cowen

Good afternoon. John, I want to make sure I caught what you said on the chart reviews. did you say the exposure to total chart reviews is one percent and then even smaller from the

James M. Head, CFO

unlinked piece yeah for us yeah we don't we don't rely on that much at all is really the message

Ryan Langston, Analyst — TD Cowen

we don't feel exposed by that change at all yeah okay and then i mean is it fair to maybe assume the split is more just 50 50 within that sort of one percent uh not sure i understood that

Speaker 10

I just don't think we're going to get precise about that because it's so immaterial. It's a small number. It's a small number.

Ryan Langston, Analyst — TD Cowen

And then I guess just building maybe on John's question and, John, your remarks about sort of deepening broker relationships, a direct non-competitor to you guys in your markets announced some plan to use MA brokers more like health navigators and get them involved in patient experience. I guess, is that sort of a strategy you think could work for the industry? And maybe just more broadly, how do you believe the payer-broker relationship will or could evolve sort of over time?

James M. Head, CFO

Yeah, I mean, we have been consistent about this. You know, we value our broker partners. We think they do a good job. We think they're generally, you know, looking out after the best interest of the beneficiary and are fair. What I do think is going to be interesting is how CMS tries to position itself as a bit of a, call it a, if not the actual agent of, you know, a little bit more of the FMO. I think that'll be interesting. And we're kind of looking at some of that, some of the developments, some of the just, it's very nuanced. But I think that's going to be interesting, one to watch. Not sure it's going to be implemented anytime soon, but I think that's on their radar. You know, with respect to your kind of commentary on some of our competitors, you know, I don't know. I think they were, you know, I think very specifically saying that, you know, whatever it is, four to six percent of premiums going to distribution is a big, big line item, I think is what was quoted. Yeah, I'm not sure. I'm not sure. I mean, there's certain parts that they can maybe be additive to a little bit, but I'm just, I'm not sure about that one. Appreciate it.

John Kao, CEO

Thank you. Our next question comes from the line of Witt Mayo with UREP Partners. Your line is open.

Witt Mayo, Analyst — UREP Partners

Hey, John, can we go back and talk about the D-SNP growth in some of the non-California markets? Are there any numbers that you can put behind that? And then also maybe just elaborate on the potential opportunity in the coordination-only duals contract in Nevada. Thanks.

Speaker 10

yeah and and uh i'll i'll take the uh the growth issue if we about 50 percent of our aep growth was in the lis duels and c snip um and that was both in california but also outside of california as you know we have strong cal uh outside california growth so that's that's a real healthy portfolio for us um and you know we we think we can manage that pretty well over time and with a lot of embedded value. But, John, I think there's a second half of the question. Maybe I'll give it over to you.

James M. Head, CFO

Yeah, I actually need to follow up with you on that one. I don't have a good answer for you.

Witt Mayo, Analyst — UREP Partners

And my follow-up would just be with some of the STARS changes, that if CMS deletes the 12 measures in STARS, is this a good or bad thing for you? I know you had some twos and threes in some of those measures.

James M. Head, CFO

Yeah, we've looked at it. I think it's net neutral is kind of the bottom line. You know, I think it does get implemented. It's probably not going to actually take root, you know, until 27 anyways, which means it'll impact 29, maybe 30, you know, 20, 29, 20, 30. But net, I think as of now, we think it's effectively a net neutral. I do think CMS is going to try to, you know, simplify that whole stars. program. And so we actually think that's actually a pretty good thing. Thanks, Gus.

John Kao, CEO

Yep. Our next question comes from the line of Jessica Tassen with Piper Sandler. Your line is

Jessica Tassen, Analyst — Piper Sandler

open. Hi, guys. Thanks for taking the question. Can you maybe give us a little more detail on the slope of MDR over the year? I think you mentioned typical Part C seasonality and then flat MBR, slattish slope in Part D. So just trying to understand excluding the sweep in 25, will calendar 26 follow kind of a similar seasonal cadence?

Speaker 10

Yeah, next to the sweep. And as you're aware, history has shown itself pretty consistently that Q1 and Q4 are kind of the higher MBRs. And then not even with the sweep, but just in Q2 is usually our seasonal low, and then it picks up in Q3. So, I think it's going to follow a similar pattern, Jess, and I think you're kind of seeing that in our first quarter guidance.

Jessica Tassen, Analyst — Piper Sandler

Okay, great. Thank you. And then just my next one is, can you all discuss retention during AEP and then on the lower projected intra-year growth in 26 from 1Q to 4Q? Is that a matter of lower growth ads or increased intra-year turn or switching? I'm just trying to get a sense of basically year one versus tenured membership in the mix of year one versus tenured in 2026 yeah why don't I when I

Speaker 10

tried the first the second question first which is the entry year and then we can talk about retention but you know as we as we come into this year there was just a lot lot more movement disruption is probably too strong a word because we weren't picking up bad stuff but there was just a lot of movement and And so we we are trying to assess whether we picked up most of that movement in AEP or whether it will sustain itself throughout the year. So it's a little bit like we're not ready to bank on a greater AEP opportunity turning into sustained growth throughout the year. OEP is, you know, feeling fine, but the we just aren't ready to kind of bank it all the way through December. And then as it pertains to retention, I think we talked about it in January at the conference. We felt very good about the retention this year. That was one of the reasons why we had, you know, kind of very nice. But we had both sales growth, but we also had retention. And that's wonderful for us because of our ability to mature our cohorts and get better MBR. So, when we're not churning them, we're holding on to the loyal members. So, that's turned out to be a nice little boost for us.

John Kao, CEO

Great. Thank you. Thank you. Our next question comes from the line of Andrew Mock with Barclays. Your line is open.

Speaker 6

Hi. This is Tiffany Yvonne on for Andrew. I just wanted to follow up on the advance notice. You mentioned your exposure to the unlinked chart review is fairly limited. Can you share what you think your exposure is to the risk model rebasing component relative

James M. Head, CFO

to the industry? That's an interesting question. I actually don't think we are as exposed as others for the simple reason that our kind of blended draft schoolers are, you know, what are we Jim, 1.08 or something like that i mean it's just 1.1 yes yeah it's below 1.1 you know and even with the the final phase of the 28 you know you still got people coming down from 1.5 1.6 2.0 in certain markets you know down because 20 some odd percent and so i i just i think we're we've never relied on it other than to make sure that we're just very accurate and compliant on the coding part and have focused on the cost management side and the star side. And I think we're going to be advantaged, actually, if there's any more tweaks to that.

Speaker 6

Okay, got it. And then I just wanted to follow up on the MLR seasonality. I appreciate the comments around sort of the blended seasonality. but could you remind us how your Part D MLR specifically progressed through the quarters in 25 and is your expected 26 slope consistent with that 25 experience? Yeah, it will be slightly

Speaker 10

different in 26 than 25, which is to say that the profitability of Part D is going to be a little bit more weighted to the first half, but this is all in the margins. So I would kind of say at a high level consistent but slightly more weighted to the first half and that's just really kind of the construct of of um uh the risk quarters and and how we accrue uh for contra revenue uh when we're outside the risk order etc so i would say pretty similar to 2025 a little bit flatter okay

John Kao, CEO

thank you thank you our next question comes from the line of jonathan young with ubs your line is

Jonathan Young, Analyst — UBS

open. Thanks for taking the question. John, I think you mentioned that you're still in some provider engagement or negotiations in the new state. I guess what in your mind is currently the hang up there and typically where are you in terms of when you're thinking about entering a new state? Would you normally be completed at this time or would it be a

James M. Head, CFO

little bit further down the road? It depends. It's a good question, John. It depends. Really we're looking for full provider durability, full provider engagement, and I think we're going to get there. It's just, again, our lessons learned over the past several years in terms of entering new markets is just causing us to be extra vigilant and to make sure people understand our model, why we're different than everybody else, and it really, even if you work with different health systems and integrated delivery networks and whatnot, a lot of it really relates to the physicians and to create economic, clinical, and operational alignment with that doctor and or their mso and and that's really what i was focusing on i think we've got great you know hospital partners and we've got a lot of uh good doctors that understand and like what we're saying in terms of the clinical model um we just need we just i would like to have a few more

Jonathan Young, Analyst — UBS

that's all gotcha okay and then just going back to um the rate update for 27 it wasn't clear to me because i think at the beginning in your paragraph remarks you said that um the industry is complaining about what the effective growth rate is but then it sounded like it was fine for you but then i believe later on you said that it is running below trend in terms what it is? I just want your clarity on that.

James M. Head, CFO

Yeah, the 0.9% net kind of advance rate notice I think is clearly disappointing to the industry. I think there's a little bit of debate over what's causing that low trend, and I think that CMS has certainly shared with us that it was really just an actuarial reality when they used different data for more recent dates. relative to what was used in the past. So their intention was not, you know, kind of programmatic policy issue, but it was just like the data was different. And that's what led to a little bit lower than expected raw traditional fee-for-service trend. Then in addition, you deducted these skin substitutes as an offset to that, And ergo, you kind of get this 0.9%, which is a big problem. If that maintains for the rest of the industry, people are going to be rationalizing benefits again. And so my point was I heard somebody say 9% to 10% from one of our competitors. I'm just not sure I've seen that number. And so if you then, if you think about the fee-for-service trend data, and let's say you get a portion of the skin substitutes, if not all, but let's say a portion is actually used as an offset and then it's phased in over time, I think you could see kind of, you know, closer to what the other analysts was talking about, 5%. You know, I have heard a lot of people talk about 200 to 300 basis points increase, kind of getting 0.9 to, you know, increase to 200 to 300 basis points, which gets you to, you know, whatever, 3 to 4 percent, 5 percent increase potentially. But my point was I think that's still lower than kind of the utilization trends that would cause people to be aggressive on benefit designs. That's what I really meant. My point as it relates to alignment is I really think we can win either way because we're the high quality, low cost producer. We're not dependent on, you know, kind of an external entity to do our medical management. That's something that we're actually very good at. And what we've also said is the margin that would otherwise go to a third-party value-based provider, we actually reinvest to the individual practitioner and or to richer benefits. So I just think either way, we're going to be in a really good place. From an industry perspective, I hope they're right, actually, that you're going to get a rate increase of 9% to 10%. I'm not sure that's going to happen.

Jonathan Young, Analyst — UBS

Okay, great.

John Kao, CEO

Thank you. Our next question comes from the line of John Ransom with Raymond James. Your line is open.

John Ransom, Analyst — Raymond James

Hey, good evening. Just thinking about bending the trend with Ava, you know, 1.0 was, I think, Pop Health, 1.0 was CHF, COPD, type 2 diabetes. If it's going to become more about bending the trend, what's kind of 2.0 in terms of deploying your assets to do that?

James M. Head, CFO

Really good question.

John Ransom, Analyst — Raymond James

I thought it really was, John, so I appreciate that.

James M. Head, CFO

No, your questions are always so, like, advanced. No, they really are, John. So I think two things. It's actually a serious, serious answer. I think that as good as we are, we can do a lot better operation. And so what I mean by that is I think our stratification models can be more precise. I think our workforce management of our clinicians can be more efficient. I think we, focusing on clinical outcome measures, as what you talked about, which is kind of traditional, you know, chronic disease management, I think the outcomes measures are going to be more and more important, where we demonstrate not only the efficacy of, you know, better utilization, but, you know, better clinical outcomes. outcomes. I think that's going to be something we focus on. But in terms of programs, I think transitions of care programs we can do better on. Case management efficacy we can do better on. Tighter integration with our provider partners from a medical management perspective and potentially on palliative programs, I think we can do better on. And when you kind of combine all these together, I think they all represent small opportunities for we just continue bending the cost curve. The other thing I would say is, and I've alluded to this in the past, and this is less of a clinical MLR piece but an overall MLR piece, the supplemental benefits right now that we have, whether it be dental coverage or vision coverage or transportation or flex card, those kinds of benefits represent about 5% of overall premium. And I think that we're getting big enough now that we are going to be investing in starting, buying you know it's kind of some of these um captives these specialty company captives and i think from that we ought to be able to save on margin because we would be paying ourselves basically and if we did a i'm just picking on a whatever you know whatever whatever specialty we do we'll be able to seed it with you know 300,000 ish uh seniors you know if you know what i mean And so I think that's going to be a way where we bend the cost curve. The other thing that we've also talked about is, you know, one of the benefits of our performance in 25 was we really working closer with these IPAs that we have and taking the technology tools and really helping them do the utilization management for the acute authorizations. And I think we've done a very good job. And we're operationally good with them. We have some work to do, I still think, in terms of some data. But I think by de-delegating that has been something that's going to help us and help the member and help the IPA. And I think that before this past year, we hadn't done that. And so the full benefits of AVA and Care Anywhere weren't fully realized yet. So I'm very optimistic about that part.

John Ransom, Analyst — Raymond James

That was quite the answer. My second question is a very simple one. there are studies as long as your arm about is MA a good deal for the taxpayers? If you do apples to apples, yeah, risk, risk adjust, apples to apples. Where do you, I mean, you've got MedPAC on one hand saying it's terrible. There's the Evolent study on the other hand saying it's a great deal. And there's all over the, when you talk to people in DC, what study do you point to? And do you think, do you think it's apples to apples a good deal yet for the taxpayers?

James M. Head, CFO

I think it's a, I think it's a very good deal for the seniors. I think from a tax point of view, the last study I saw is post-B28. It's pretty much apples to apples is what I saw. And to the extent that plans that are able to remain competitive and still have a reasonable rebate back to that beneficiary are going to be the winners. And I think that CMS has been consistent with they want to grow MA. They just want to grow it the right way. They want to minimize the gaming, their words, not mine, and ensure program integrity. On the other hand, they want to have an alternative with what they're referring to as traditional fee-for-service Medicare. Now, I just, I think, you know, just looking at the value proposition to the beneficiaries, I personally think you're going to get continued growth and market share growth in MA. Because the rebate dollars, even if they go down, they're still material enough in terms of being better than fee-for-service that people are going to still choose it. Thank you. You got it.

John Kao, CEO

Our next question comes from the line of Raj Kumar with Stevens. Your line is open.

Raj Kumar, Analyst — Stephens

Hey, maybe just one quick one around kind of AEP and just thinking about new member engagement, kind of pertaining to the Care Anywhere platform. Any kind of insight on that and how that's trending relative to kind of this time last year?

James M. Head, CFO

Hey, Raj, it's John. Can you just repeat that again? I kind of faded out, or you faded out. I didn't quite.

Raj Kumar, Analyst — Stephens

Sorry about that. Yeah, just maybe kind of any details around kind of new member engagement and kind of pertaining to the Care Anywhere platform and how is that trending relative to kind of this time last year with the new membership?

James M. Head, CFO

Yeah, I got it.

Raj Kumar, Analyst — Stephens

Yeah, I would say it's about the same.

James M. Head, CFO

I think there's opportunity for us to get better. We're spending a lot of time, again, you know, taking advantage of, again, the, I think, the correct strategic decisions and operational decisions we made two years ago that are really paying off in 24 and 25 and I think will also pay off in 26. that same kind of operational focus of continuous improvement, again, just not being satisfied with any of it is going to cause us to get better and better and better. And one of those areas is Care Anywhere engagement. I think we were still at about 65%, which really isn't bad, but I think we've set a target internally. We're trying to get to 75%. And I think some of the new people that we've brought in on the member service and member experience side, shout out to that team, is really going to be good for the company and for our beneficiaries. So I'm optimistic about that. But year to year, to answer your question, it's about the same.

Raj Kumar, Analyst — Stephens

Guy, then just maybe as a follow-up, just kind of thinking about your ex-California markets and kind of been in them for a while now and as they've matured, have you kind of seen any divergence in just overall trend or even consumer behavior and how maybe that has kind of led to operational kind of nuances in those distinct markets and maybe even kind of any catering or tweaking around AVA to kind of service those operations in the kind of most optimal manner? That's a very good question.

James M. Head, CFO

I think the work that we're doing now in terms of, I call it operational scaling, is really designed to make sure that the providers and the members outside of California get the same level of service they get inside of California. And that's part of our maturation. It's part of our scalability. And we're working really hard on that right now. again, having very clear member satisfaction, but we're really starting provider satisfaction metrics. And I think the bigger we get, the more critical this area is, particularly outside California. I think we've done a very good job on stars. I think we've done a very good job on clinical replicability in terms of the ADK metrics outside of California. I think our provider engagement is something we got to just get better at. And I say that to all the providers out there. We're working on it. We're going to get really, really good. And we want five stars from all of you, just like we got five stars from the members. Great. Thank you. Thank you.

John Kao, CEO

Ladies and gentlemen, that's all the time we have for questions. This concludes today's conference call. Thank you for your participation. You may now disconnect.