Conference Transcript - OSCR 2026-06-08

Scott Fidel, Analyst — Goldman Sachs

Okay. Well, thank you for joining us for the next panel. We're really pleased to have Oscar Health with us for the next panel. I'm Scott Fidel. I'm the health care services analyst here with Goldman Sachs. Joining us today from Oscar, we've got Scott Blackley. He's the chief financial officer. And then also we have Bianca Rodriguez from Investor Relations, who's also in the audience with us today. So, first of all, Scott, great to see you. And welcome to the conference. It's great to have Oscar, and it's great to have you here as well. We've got a nice list of questions and conversation that we're going to have. But, Scott, I thought maybe first you didn't have an AK out this morning and had sort of an allusion to a business update. I'm sure we'll get into that. But maybe I'll sort of kick it over to you if there's any initial comments you wanted to make and sort of set things up for the conversation. Great. Thank you. Good morning, everyone.

Scott Blackley, CFO

Yeah, so why don't we start off with just a quick update on where we are with the business as we've closed out the month of May. I would say the 26 is off to a very strong start. You know, we spent several years planning for how 2026 was going to play out with the expiration of enhanced subsidies. I think a lot of that planning work that we did is showing up in the results that we're seeing. As you talked about, Scott, we did file an AK this morning and just reaffirmed our full-year guidance. But behind that affirmation of our current guidance, we do see some pretty healthy tailwinds in the performance of the company. You know, first off, I would just say that when it comes to membership, we continue to see trends as expected. So we finished open enrollment with 3.4 million members. That migrated down to about 3 million members at the beginning of Q2, and, you know, things are proceeding as more or less as we would expect from there. On utilization, utilization through May has been, you know, and continued to be modestly favorable to our expectations, so continue to see strong performance there. And then, you know, another important update, we did receive the final 2025 Wakely report. This report is based on the actual data that the carriers submit to CMS, so it tends to be the most accurate Wakely report of the year. And that report was $130 million favorable to the accruals that we had booked in the first quarter. So, you know, a pretty significant tailwind to where we were at the end of the first quarter. So, you know, I take all that together. I think there's some pretty strong tailwinds. But given that we still are waiting for the first 2026 Wakely report, which gives us a bit more information about the market morbidity this year, We are holding off on making any updates to our guidance at this point in time, but I think we go into the quarter close this month with a pretty strong tailwind.

Scott Fidel, Analyst — Goldman Sachs

All right. Well, great. Thanks for those updates, Scott. That's encouraging and also helps to provide some nice visibility into trends year-to-date. And certainly those are three topics that we were going to want to discuss, So to the extent that we can drill further, looking forward to doing that. Just first, on the first formal Wakely report, the June report, can you just, to the extent of, you know, I know it's coming in June, what would you sort of, you know, guide investors to in terms of when expected that report would come out?

Scott Blackley, CFO

Yeah. So we tend to get the Wakely reports. You know, the first one we'll get here, we should receive it at the end of this month. We'll run, we'll have claims through April. And then each report has claims, you know, for an additional 90 days. So we tend to get a report from them every month, and, you know, obviously the first report has got a light amount of claims data, and so, you know, it is, we typically look at it as just indicative of how does it compare to our expectations. last year we saw that market morbidity was certainly accelerating in a way that the market hadn't expected so it can give you information even though it's early so we will we should have that report again by the end of this month and we're looking forward to seeing it because a lot of what the research that's come out from third parties our own claims data you know, is suggesting that market morbidity in 26, which we all went into this year with assumptions that it was going to increase pretty dramatically. You know, it looks a lot of the early signs are suggesting that it is probably going to come in a bit lighter than what we all expected, which would be good news for us. In fact, you know, Wakely had published an early report on market morbidity, market sizing in April. And that report had a range of market morbidity, which actually was lower than what we had built into pricing. And so, you know, if indeed we see that market morbidity come in favorable, as the Wakely early report had suggested, you know, that gives us an opportunity, you know, for some upside for the year.

Scott Fidel, Analyst — Goldman Sachs

And maybe we'll even step back and we'll just, why don't we just stay on Wakely since we're already there

Scott Blackley, CFO

and just sort of make sure that we cover each of the steps

Scott Fidel, Analyst — Goldman Sachs

and sort of getting to where we are now. So first, going back to that final 2025 report, and like you said, it is, while it's a 2025, it has earnings implications, as you just talked about. Maybe can you provide us some more information, visibility around the particular inputs that ultimately informed those revisions to your accruals when thinking about sort of data, sort of what you saw around the overall market and around morbidity and around the risk profile of the market and then relative to how you were assuming that, you know, for Oscar versus the market, and then we'll sort of move to the interim report.

Scott Blackley, CFO

Yeah. So, you know, the 25 report that we got, typically there's not that much variability between the final Wakely report and the final CMS report, which will come out later. So, you know, from here, don't expect, at least historically, there hasn't been much volatility. So, you know, we feel like that's a good estimate of how 25 is closing out. And I think that what the really good news about the weekly report, I'll take the $130 million as a tailwind to the year, but seeing that market morbidity was not accelerating at the end of 25 as much as we and the rest of the market had expected, like all of those assumptions ultimately got built into our guidance, got built into our pricing. So while it's a positive for, you know, our prior period development, it is also a persistent tailwind to 26 because of the way we thought about market morbidity and our pricing. You know, I just comment on, you know, overall risk adjustment, as you know, is the most challenging part of our business to predict. We have to predict our own risk scores, and we have to predict the market risk scores. seeing 25 and how 25 is coming out also gives us an additional lens for predicting 26. And so, you know, it helps us to refine our models to understand better what's going on on a state-by-state basis and to be able to, you know, kind of be ready to receive that first

Scott Fidel, Analyst — Goldman Sachs

weekly report. And then how much do you discount or are you able to bridge some of the unique dynamics around 25 versus 26, just given, you know, the more extreme or material sort of change to the marketplace just because of the sunset of the enhanced subsidies and the resulting, you know, particularly sort of changes into sort of metal-level products that we've seen play out so far this year? Yeah, I think for 26

Scott Blackley, CFO

we have, as as a industry, I think we have more information about market morbidity earlier in the year than we've ever had. The Wakely report that I think we and, and, and others, you know, sourced information gave the, you know, we gave that to Wakely early in the year, which, which they took and then gave back an early read on what is market morbidity looking like for 26. It's the first time we've had that report. You know, we also got additional third-party data about our incoming membership, which gave us much more information about the risk scores and the potential utilization of our new members. So we walked into this year, I think, with more information than we've ever had about the membership. You know, since then, just the read-through from first quarter, it looks like, you know, we didn't see any of the competitors that had, you know, called out significant pressure on utilization, our results, you know, were, our utilization was favorable to our expectations as well. So, you know, when I kind of take that information in the aggregate and look at how is 26 playing out, there, you know, I keep looking for some piece of bad news about 26 market morbidity. And at this point, you know, just haven't seen any. Yeah. Yeah. Well, certainly,

Scott Fidel, Analyst — Goldman Sachs

I mean, relative to the, you know, I think the fear levels or just uncertainty, you know, around how much the market could, you know, see a deterioration of the risk profile because of the loss of the subsidies and then the sharper premium increases, it's certainly encouraging to see that. And, Scott, to what extent can you sort of line us up with that in terms of that favorable underlying sort of variance around morbidity relative to maybe some of the assumptions that you had before that were in the accruals? And then, again, I think also consistent with how the industry was thinking about things, in terms of, like, what are some of the underlying inputs into what you're seeing that's coming in more favorable? Is it, you know, in terms of demographics of the membership, in terms of sort of the product, again, you know, sort of shifting more into the products that, you know, ultimately, I mean, again, that, you know, may actually affect some of the utilization dynamics, which we'll get to. Are there any particular characteristics that sort of jump out, you know, particularly?

Scott Blackley, CFO

Yeah. I would say that given the amount of change that was happening in the marketplace with the expiration of enhanced subsidies, I think we and others, including the consulting firms, were probably as conservative as we could be in terms of trying to estimate what the effects of the loss of those subsidies would be on the marketplace. I think that, you know, Oscar has been working backwards from an assumption that the subsidies would expire in 26. That was when we did our last investor day, you know, a couple years ago now. That's the guide that we came up with is in the event these expire, here's what's going to happen. We were hopeful that they wouldn't, but we were planning, you know, for the worst case scenario that they would. And I think that that has allowed us to really approach the market from the lens of what are the right products that need to be in this market if those subsidies are gone. And that really informed how we built our bronze plans, our gold plans, and, you know, to a lesser extent, silver. because what we were trying to do is to make sure that we had plans that could give those individuals that were able to maintain benefits or some type of subsidy a landing spot where they could go to gold and get rich benefits using the subsidy dollars that they had. They could go to bronze and get potentially a cheaper plan, not have an out-of-pocket increase but still maintain coverage and that strategy was really successful in both allowing us to retain our own members but also collecting a lot of members from other plants or new to the marketplace so really I think that when we look at what happened this year you did see a fairly significant change in metal demographics and at least in our case you know, that was very intentional, something that we had worked for, you know, for quite a long time. And we think that was, you know, a huge reason for the success this year.

Scott Fidel, Analyst — Goldman Sachs

Well, certainly what we're talking about right now is going to have, I think, pretty meaningful implications for how you're thinking about 27 strategies. So, well, let's put an asterisk on that. But I first want to sort of fill in the updates that you provided and sort of continue to sort of build out that mosaic of the inputs to 27. So I think this is a good transition, you know, towards utilization, and I very much appreciate you giving the updates so that we can actually talk a little bit about, you know, some of the backdrop around utilization. And certainly, you know, not a significant surprise to hear that the bias may be more towards favorability just in terms of what we're hearing, you know, out in the market and with all the checks that we do and then obviously the rest of the street does as well. I guess to start with, Scott, can you, any more additional layering that you can give us around just when sort of as that sort of bias towards favorability in terms of the cost components or, you know, the key provider settings? Are you generally seeing it sort of broad-based or are we seeing, you know, Clearly, it feels like on the hospital front, we've definitely felt like things have maybe, you know, sort of come in a little bit more than the hospital is expected. But I don't want to put words in your mouth of what you're seeing out there.

Scott Blackley, CFO

Yeah, I think I'll save the details of, you know, the categories of utilization for our full quarter update. But I would say that there's always puts and takes that you see along the way. So, you know, we are seeing exactly that. There's some areas that are running, you know, really quite favorable. There's other areas that are running, you know, a little bit unfavorable in the aggregate, which is, you know, what I really focus on. You know, we're seeing utilization that is kind of persistently grinding favorable each month. And so, you know, that's a real positive. of, you know, I think that there's a question about how much is AI, you know, in the background starting to affect whether it's hospital systems or the way that Oscar utilization, you know, we've been working to make sure that we remove friction from our member experiences. And that's always been kind of, as you know, the entire history of Oscar has been built around that concept, and I think we've been, you know, pretty methodically doing that over a number of years, but we're really starting to see some of that, you know, kind of working its way through towards more predictable utilization patterns because, you know, we know what type of things go straight through and get approved by us, what things need to actually go in for a clinical review, but it, you know, it is something that I think you're starting to certainly see the hospital systems using more AI to help them with coding charts, and so, you know, I think that potentially a lot of this utilization favorability can be, you know, kind of attributed back towards just more efficiency in how we all manage, you know, patient interactions.

Scott Fidel, Analyst — Goldman Sachs

All right. And then getting back to just the membership dynamics and how that's tracking. So it sounds like things are right on track with your book of business. How would you characterize the overall market at this point? It feels like, you know, from our perspective, that we're probably right in that mid-20s, you know, type range if you sort of aggregate everything that we've seen in terms of down mid-20s and I know that's part of the range that you've provided as well. Does that still sort of make sense to you, or are you going to buy it in the direction?

Scott Blackley, CFO

Look, I think that our estimate was that the market would contract by 20% to 30% in 2026. We priced morbidity assuming a 30% contraction, And that, you know, currently our risk adjustment accruals are based on that pricing view of, you know, a 30% market contraction. I just, you know, like you, I read everything I can get my hands on. And I just see nothing in any of the competitor data, our own data, third-party, you know, kind of reviews that would suggest that it's going to be at the higher end of the range that we provided, the 20% to 30% range. So, you know, we'll see how it all plays out. I'm super excited to see this weekly report just because while we think we've got good data that's going to help us understand how the year is going to play out, seeing that first confirmatory report will certainly give us even another layer of support behind starting to lean in and feel like, okay, market morbidity is going to come in below where we had all expected.

Scott Fidel, Analyst — Goldman Sachs

So let's talk about sort of where we sit right now and to the extent that we can sort of tease out some of your thinking around, you know, the outlook for 27 and some of the key variables that may be a consideration around game theory and around how you're going to position pricing and how competitors are. So, I mean, there are some interesting, you know, cross-currents here, right, because certainly it feels like the market is performing, you know, better than feared so far this year. Obviously, we're coming off of a pretty, you know, a pretty dynamic, a pretty brutal, you know, last year for the sector in the exchange market, but also more broadly in all the key markets on the government side. So margins have certainly, you know, been beaten down in our view is that, you know, the industry is sort of in that inflection towards cyclical recovery, you know, across some of these markets. We're seeing some of the, you know, some of the key things that we track are certainly around capacity, you know, as part of our sort of different sort of key sort of critical inputs on the underwriting cycle. And it's definitely, you know, sort of as would be expected in terms of this late sort of cycle, you know, sort of period, we've been seeing more announcements of market exits, you know, from carriers and more, you know, from regional and provider-sponsored carriers, the types that we would generally expect. But it's a steady tempo, you know, there. And so you're going to want to sort of get your opinion on sort of to what extent, you know, that capacity dynamic sort of, you know, may influence your thinking. You know, but ultimately, you know, I think it's like ultimately it's like the big sort of choice or pick, right, is going to be like are we going to – side, you know, more on the exchange side after seeing some of this favorability, or is it, you know, the broader sort of pressure that the industry has faced across multiple lines, and again, still, you know, a market that is shrinking 25 percent and has a lot of underlying, you know, sort of, you know, variation going on in it, do you think that that ultimately keeps, you know, a disciplined sort of, you know, balance around that price versus margin. And there's a lot in there, but, you know, the game theory that you may be thinking about at this point.

Scott Blackley, CFO

There's a lot to unpack. And so I would say 27 has some, you know, new set of regulatory requirements for the marketplace. As we think about, you know, pricing for 27, and trying to figure out how are each of the different new regulatory standards going to affect the size of the market. We did see, you know, another piece of litigation come out that, you know, last year many of the program integrity efforts that CMS was trying to put into place ultimately got stayed by the courts. And a similar lawsuit was filed recently, same court systems challenging some of the new rulemaking that CMS has just released. So there's a little bit of a lack of, while we know what the final rule proposal is, and we're working to build that into our pricing, we're also going to have to be thoughtful about having an alternative pricing scheme that says, what if some of the current proposed or some of the current regulations ultimately get stayed again.

Scott Fidel, Analyst — Goldman Sachs

So they're meaningful enough that you would have to...

Scott Blackley, CFO

I think that there's some important things that would cause us to need to adjust some of the key inputs that go into pricing. So we'll be carefully monitoring that.

Scott Fidel, Analyst — Goldman Sachs

When would you expect to have visibility into that?

Scott Blackley, CFO

That's a court matter, and we would be hopeful that it gets resolved quickly. At least they've got some precedent about from, you know, how it was handled last year. So there's some, you know, optimism that we could see this get, you know, rapidly resolved. But like all things in the government, you know, surprise is probably more likely than not. So we'll keep a close eye on that. You know, I think that the thing that I learned most specifically about 2025, my biggest takeaway from that is when you know what is coming, even when the changes are pretty significant and we are able to price those into the assumptions that we use, and actually within a relative range, we're able to predict what's going to happen in the marketplace. When things change mid-year is when it gets pretty bumpy. And when you have a lot of, you know, mid-year regulatory changes or mid-year, you know, membership, you know, changes in who's allowed to access the marketplace, those are the things that I think create the most volatility. So I'm pleased that we're going to try to get some of these things for 2027, you know, looks like we'll have clarity on how 2027 is.

Scott Fidel, Analyst — Goldman Sachs

And at least this year, too, there's not all that.

Scott Blackley, CFO

So, while it may seem like it's more dynamic, you know, I actually view it as being a bit more structurally consistent each year where we know kind of what is happening in the year, we're able to price for it. So, that gives me some optimism about being, you know, the predictability of the market. You know, this is a very hard business, incredibly important. I think that for what you see is those who have been in this business and are staying in this business tend to have networks that are built, you know, neural networks. You know, some have Medicaid chassis. We've gone to the market with more of an approach of let's build neural networks. I think that you've seen others who've tried to use a commercial network, You know, just struggled to be able to be competitive with that type of backdrop. And so, you know, there are some carrier exits this year. We have a pretty good overlap with the markets where those carriers are. So that gives us, you know, an opportunity for 27. But overall, I think that the 25 was a tough year for everyone. I'm not sure the 26 is going to be quite, you know, that we're all going to conclude that we've completely recovered to where we need to be. So I know that, you know, when I look at the marketplace and I think about how we're approaching pricing, I would characterize it as, you know, competitive, but also, you know, this isn't a marketplace where you win by being, you know, significantly the lowest price because that just doesn't get you anywhere. So I would expect it to be a rational market in terms of pricing.

Scott Fidel, Analyst — Goldman Sachs

I have one more question on the exchanges, and then I want to sort of open it up to see if there's any questions in the audience and then we'll see how much Lucy and Icra we can get in with the time. The final question of the exchanges is just around, again, that sort of where we stand with market and program integrity and the numbers, you know, that we continue to still see around sort of how much a proper enrollment may or may not be, you know, in the market paragon, just put out their update And they're still calling that a very substantial relative, especially with the, you know, against the size of the exchange market this year versus last year. Obviously, you know, Oscar has a tremendous amount of technology sort of monitoring things for your – what's your observation, you know, on maybe just sort of that, the Paragon view or just the general, like, let's say more, you know, much more cautious view on – on some of those, you know, on the accuracy of all the enrollments that are in the market?

Scott Blackley, CFO

Well, look, I think that the Paragon Report clearly has a lens that they're trying to paint on the marketplace. You know, they start with the 23 million open enrollment and use that as their proxy for how many people, you know, were inappropriately enrolled. We think that's more likely, you know, or should be, your starting point should be kind of the post. And so there's already inflation. And it's also based on some census data that is known to be, you know, it's lagged. The census themselves will say that they are very ineffective at capturing data for low-income populations. and immigrant populations, and I think those are important pieces of data in terms of what's going on with the marketplace. So, you know, I think that we know the folks at Paragon, they're obviously smart people, but I do think there's a little bit of a purpose for their report. When we look at things, you know, our view is we think that, you know, a stable marketplace is best for all the ACA participants. It's the best thing for Oscar. And so we support, you know, thoughtful program integrity initiatives. We think they're good. In our own book of business, we do bring AI to look for anomalous patterns amongst members, amongst brokers. When we see those things, we suspend brokers. If we see, you know, patterns that we deem suspicious, we, you know, have a constant dialogue with CMS about, you know, anything that we're seeing. So we try to be very front-footed in protecting ourselves and the marketplace from fraud. If we think that there's, you know, suspicious behavior amongst members, we don't recognize the revenue on those members. So, you know, we're trying to make sure that we set the company up to be successful in a world where, you know, we want to be a market leader in making sure that this is a clean and healthy marketplace.

Scott Fidel, Analyst — Goldman Sachs

Well, we probably have time for a question or two from the audience. if anybody has anything that cares about?

Scott Blackley, CFO

Yeah, the question being with as much power as the current administration has to create rules, you know, what happens if you see a change in administration and how likely is it that we might see, you know, a flip-flop. I'm sure there's a handful of initiatives that, you know, if we did see a different administration in power at some point in the future, certainly they would have their own set of agendas. What I think that, you know, will likely be sticky is some of the program integrity initiatives that have been put into place. I would expect to see, you know, those continue. I think some of the expanded open enrollment or SEP type of characteristics that were put into place during COVID, I don't think those will be, you know, we'll see those return. So I don't want to get too far ahead of ourselves, but I think that the parameters of what can be, you know, what would be different are narrower than maybe they've been in the past because I think the market's going to be more stable, you know, going forward.

Scott Fidel, Analyst — Goldman Sachs

Well, great. Well, I think we're right at time, so we're going to pause the session there. And, Scott, I want to thank you so much for joining us and hope the rest of the conference goes well for you.

Scott Blackley, CFO

Really appreciate it, Scott. Thanks for your time. You're welcome. All right. Take care.