Centene Corp (CNC) — Q1 2026 Earnings Call Transcript

Thank you, Rocco, and good morning, everyone. Thank you for joining us on our first quarter 2026 Earnings Results Conference Call. Sarah London, Chief Executive Officer; and Drew Asher, Executive Vice President and Chief Financial Officer of Centene, will host this morning's call, which also can be accessed through our website at centene.com. Any remarks that Centene may make about future expectations, plans and prospects constitute forward-looking statements for the purpose of the safe harbor provision under the Private Securities Litigation Reform Act of 1995. Specifically, our commentary on our full year 2026 outlook, including the drivers of such outlook, are forward-looking statements. Actual results may differ materially from those indicated by those forward-looking statements as a result of various important factors, including those discussed in our first quarter 2026 press release and other public SEC filings, which are available on the company's website under the Investors section. Centene anticipates that subsequent events and developments may cause its estimates to change. While the company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so. I will also refer to certain non-GAAP measures. A reconciliation of these measures with the most directly comparable GAAP measures can be found in our first quarter 2026 press release. With that, I would like to turn the call over to our CEO, Sarah London. Sarah?

Thanks, Jen, and thanks to everyone for joining us. This morning, we reported first quarter adjusted diluted EPS of $3.37, exceeding our previous expectations for the period. The strength of our first quarter performance enables us to increase our full year 2026 adjusted EPS outlook to greater than $3.40, up from our previous expectation of greater than $3. We are pleased to be off to a strong start this year as increased visibility and operational improvements are yielding positive momentum and lifting our overall financial performance. Results in the quarter included excellent progress within our Medicaid business as we continue to drive margin improvement through targeted and increasingly scaled initiatives to modernize and standardize processes to better manage medical cost trend. Our Medicare segment results were ahead of expectations with outperformance from both Medicare Advantage and PDP offerings. And finally, our commercial segment, the vast majority of which is made up of Marketplace, performed in line with expectations on a pretax margin basis as a slightly higher-than-expected HBR in the period was offset by favorability in segment SG&A. As everyone knows, it is early. So while we are off to a great start, we are taking a prudent outlook for the balance of 2026 as we continue to gain visibility into key factors that will influence the remainder of the year. With that, let's dig into the results. Medicaid results in the quarter were ahead of our previous projection, outperforming our HBR expectation in the period. Within that, we experienced a flu season that was lighter than our original forecast and saw a slight utilization benefit from weather events. That said, we were pleased to also deliver solid fundamental outperformance in the quarter, thanks to continued focus and disciplined execution on trend management initiatives across the portfolio. Behavioral health remains the largest driver of trend with other categories like home health and high-cost drugs continuing to be consistent contributors. That said, we are beginning to see pockets of deceleration across this cohort largely in line with our expectations for how trend would mature from 2025 into 2026. At the same time, we continue to strengthen and scale the multipronged trend program we deployed in the back half of 2024 and ramped significantly in the face of elevated trend in 2025. This includes standardizing best practices on utilization management across our markets, the addition and further expansion of successful clinical programs, ongoing data-driven network optimization to ensure our members have access to the highest performing providers, advocacy around program reform with our state partners and increasingly aggressive efforts to stamp out fraud, waste and abuse. We've discussed here at some length the work we've done around ABA, but with the benefit of more than a year's worth of data under our belt, we are seeing stabilizing year-over-year ABA trends that we believe are a direct result of the actions we have taken to ensure appropriate high-quality care for ABA members across the country. We continue to strengthen our identification of outlier providers who exhibit suspect or fraudulent billing patterns. At the same time, we continue to advocate for the ability to more fully address fraud, waste and abuse in a standardized prevention-focused posture across Medicaid programs. We recently highlighted several potential reforms in response to an RFI from CMS, including allowing proactive payment suspensions, creating safe harbors and improving two-way data sharing. We look forward to partnering with CMS and the states we serve to better protect taxpayer dollars and strengthen overall program integrity. Looking to the remainder of the year, our guidance assumes net trend, defined as medical costs net of these trend management initiatives, remains in the mid-4% range, and we continue to execute with the goal of outperforming that target. Rates are, of course, the other major contributor to our margin restoration agenda, and we continue to work closely with our state partners to ensure alignment between program revenue and member acuity. With respect to the full year outlook, we continue to track in line with our expectation for a composite rate yield of roughly 4.5%. Conversations with Medicaid departments remain constructive, and we continue to present refreshed data and in many instances, programmatic solutions for challenges our state partners are facing as they look to balance costs and benefits within the Medicaid program. It is still early; we are pleased with the momentum we are seeing across the Medicaid portfolio and we continue to see opportunity for advancement in 2026 and beyond. Our Medicare segment also delivered strong results in the quarter. Both Medicare Advantage and PDP exceeded expectations, producing an HBR of 84.9%, better than our previous forecast and contributing nicely to the first quarter adjusted EPS. In Medicare Advantage, we continue to strategically align our membership with our Medicaid footprint and made great progress on our path to positive earnings. While trend continues to be elevated versus historical baseline, it is so far consistent with what we planned for in our bids with slight favorability in Q1. Thanks to strong execution during both AEP and OEP, we are seeing a slightly more favorable membership mix and our decedent membership is now at 40% of our overall portfolio. We are also seeing stronger year-over-year member retention, the continuation of a now multi-year theme, reinforcing the value of investments made over the last few years to redesign our sales and onboarding experience. This durable member base gives us the opportunity to deploy differentiated care models and drive both quality and health outcomes for members over the long term. Business also continues to make solid progress on our value-based care strategy. The team has built a disciplined, performance-driven model that is tightly integrated with network strategy, clinical execution and cost management. We have simplified our contract structure and focused the portfolio to a partner ecosystem that we believe can truly move the needle on quality and cost outcomes. We're also deploying innovative total cost of care models against high-cost specialties such as oncology, chronic kidney disease and behavioral health. These are part of a broader portfolio of initiatives designed to build critical momentum as we look to return the business to profitability. Our PDP business ended the quarter with just over 8.7 million members, thanks to the team's once again thoughtful and data-driven approach to bid design and positioning. While it is still early, fundamental outperformance in the quarter was driven by slightly lower-than-assumed specialty drug trend, which gives us increased confidence in the trajectory of the business for the year. We are pleased that our Medicare members will have the opportunity to participate in the CMS Bridge program, and we support the goal of expanded GLP-1 access for more seniors. As the largest stand-alone Part D provider in the country, we've also been actively engaged in dialogue around the risk adjustment model and remain committed to partnering with the administration to leverage data, best practices and lessons learned from the Bridge program to position balance for success in the future. Looking ahead, we are encouraged that the finalized 2027 Medicare Advantage rates showed improvement compared to the advanced rate notice. While the final rate remains below observed medical cost trend, we continue to see a path to delivering breakeven financial results next year. Medicare Advantage and PDP programs play a vital role, providing access to care for millions of Americans, including some of the most vulnerable in our nation, and we look forward to working with the administration to identify new and important ways to fortify this program and strengthen the safety net overall. Finally, Marketplace. We ended the quarter with just under 3.6 million members, consistent with our previous commentary about post-grace period membership. Metal tier distribution and age stayed consistent with patterns we reported on in early March with just under half of our members in silver, roughly 35% of members in Bronze and the remainder in Gold. Other member demographics like age and gender remain consistent with expectations and with recent years' results. Marketplace results were in line for the quarter with a slightly higher HBR offset by outperformance in SG&A. Within these results, the Q1 HBR was driven by higher than originally expected utilization isolated in our Silver tier membership, a dynamic we foreshadowed in early March. With the benefit of additional visibility, including the new March Wakely report and more complete claims experience, we now view this utilization as consistent with the acuity of the Silver members we enrolled, and we expect this membership to receive a meaningful risk adjustment offset as we look to the balance of the year. Let me talk about the additional insight we have gained since March. After last year's unexpected volatility, Centene committed to finding ways to create additional and earlier visibility into this market to support long-term stability. Last fall, we reached out to many of our peers, all of whom were receptive to submitting earlier data on membership demographics. Wakely, the independent actuarial firm that calculates interim risk transfer estimates for the market throughout the year, agreed to aggregate and publish that data at the end of March. As a result of that collaboration, the industry has more visibility than it has ever had at this time of the year about overall market dynamics. Having received this demographic data from almost all of our 29 markets, we are pleased to see that the market overall behaved in line to slightly favorable to our expectations despite 2026 being a year of unprecedented change. First, the overall market contracted as expected in a post-APTCs environment. That said, market-by-market membership loss was in almost every market less than we expected, which suggests that more healthy members stayed in the market in aggregate and that our pricing was appropriate relative to the overall market morbidity. Second, the Wakely data confirmed a meaningful market-wide shift from Silver members into Bronze and to a lesser degree, Gold, consistent with our expectations and with a directional shift in our own metal distribution. Finally, and perhaps most importantly, this data, when combined with our final Q1 paid membership and a full quarter's worth of claims experience, strongly supports the view that Ambetter retains Silver membership with higher acuity relative to the market and that this membership will ultimately receive a meaningful risk adjustment offset. Within our Silver tier, 75% of our members were renewals, giving us a high degree of visibility into year-over-year risk score capture. Through Q1, risk scores tracked closely in line with what we would expect given our claims experience in the period. Wakely data further allowed us to see a strong, consistent correlation between markets where we lost share due to price action and an increase in the overall acuity of our Silver population. Both of these data points strongly support the mix shift hypothesis. Looking to the rest of the year, we have taken what we believe to be a prudent posture relative to our forecast for the business, not reflecting the full suggested risk adjustment offset for this population within our new greater than $3.40 guidance. The June Wakely data, which consists of claims and risk score data across the market, will be key to allowing us to further refine this assumption. We continue to believe in our ability to deliver meaningful margin recovery in the Marketplace business and look forward to updating our full year view with the benefit of the June data. Stepping back, we are pleased that the disciplined execution this quarter yielded solid financial results. As we strengthen the fundamental operations of each of our businesses, we are increasingly well positioned to deliver tangible progress against our margin recovery goals. For this work, we announced an evolution of our leadership structure earlier this month. We are pleased that Dan Finke joined the organization to serve as our Group President, overseeing the Medicaid and Commercial businesses, and we were pleased to elevate Michael Carson to Group President, overseeing our Medicare PDP and Specialty businesses. Their collective experience will be instrumental as we continue to strengthen performance across the portfolio and deliver sustainable profitable growth. I'd like to close by calling out two additional bright spots from Q1. First is progress at Centene and the entire industry have made against our prior authorization commitments, including additional commitments announced last week that will make the prior authorization process faster, easier and less expensive. In our view, this work is not about self-regulating, it's about self-disrupting. Industry leadership has worked closely together over the last 1.5 years, not because it is easy, but because it is the right thing to do for our members and for the health care system overall. I'd like to thank my peers for their awesome partnership and acknowledge the many team members at those organizations who, along with the CenTeam, are committed to transforming our systems and the system overall through an unprecedented level of collaboration and transparency. Finally, I'd like to close by congratulating the entire CenTeam for being named to the Forbes Best Employers for company culture list for the second year in a row, jumping more than 150 spots from our inaugural ranking last year into the top 50 employers in the country this year. While I'm pleased we delivered strong results in Q1, I'm even more pleased by how we delivered those results, collaborating as one CenTeam, living our values and behaviors and staying focused on our mission of transforming the health of the communities we serve one person at a time. With that, I'll turn it over to Drew to provide more details on the quarter.

Thank you, Sarah. Today, we reported a strong first quarter, including $44.7 billion in premium and service revenue and adjusted diluted earnings per share of $3.37. This was just under $0.50 better than our expectations, largely driven by outperformance in Medicaid and Medicare segment HBRs. Our consolidated HBR was 87.3% for Q1. Starting with Medicaid, we ended Q1 with 12.4 million members, slightly down from year-end. More importantly, we demonstrated continued progress in the HBR with Q1 at 93.1%, an improvement of 50 basis points from the first quarter of 2025. As Sarah indicated, our slate of initiatives on both revenue and medical expense are bearing fruit as we continue to navigate an elevated behavioral health and high-cost drug environment. While we have a ways to go to get back to a reasonable Medicaid margin, this is the third consecutive quarter of progress toward that goal. We expect continued momentum as states reflect base trend in acuity data in rates and work with us to shape successful and sustainable programs. Medicare segment results were better than expected, including an HBR at 84.9%, demonstrating outperformance in both MA and PDP for Q1. In Medicare Advantage, this gives us more confidence about the path to breakeven for 2027. And in PDP, it's always instructive to see how pharmacy trends start the year relative to expectations. To be clear, medical and pharmacy trends are still historically high in those businesses, though they were not as high as what we had built into our forecast as we actively manage cost and set bids accordingly. PDP high trends and high 2025 baseline cost, especially in specialty pharmacy, will be factored into the 2027 bids. This, coupled with the mere mechanics of a risk model that's calibrated based upon pre-IRA claims data and therefore still insufficient to address non-LIS trend, should push the direct subsidy up quite a bit again in 2027. In the meantime, we are pleased with the strong start to 2026 in both MA and PDP. Marketplace pretax earnings were on track in Q1 with a slightly higher-than-expected HBR in the quarter offset by strong SG&A management in the product. Consistent with what we told you at the March conference, our Silver metal tier members had higher than originally forecast gross medical cost in Q1 before any incremental 2026 risk adjustment benefit. We are very pleased with the early insights gained from the March Wakely data and reports. Sarah took you deeper into those observations, but suffice to say that the market size and share shifts when coupled with the metal tier distribution and our observed risk score trends are consistent with meaningful risk adjustment offsets for the higher Silver tier gross claims trends. In our current guidance, we have calibrated these factors in our membership distribution such that our forecasted year-end risk transfer assumption is for a slight receivable versus a prior payable forecast. Let me simplify all this in terms of guidance. We thought it would be prudent to embed in our current guidance a pretax margin for Marketplace around 3% for now, compared to our original forecast of approximately 4%. And as you heard from Sarah, this does not reflect the full potential risk adjustment offset suggested by the data we currently have as we await the June Wakely data. I'd also like to thank my industry peers for being receptive to this new Q1 process and recognizing an opportunity to gain visibility earlier in the year and most importantly, for timely submission of useful data to Wakely. This not only helps with 2026 forecasting, it will also give others earlier visibility of their potential risk transfer position when formulating 2027 pricing. One more thing on Marketplace. We ended the quarter with 3.58 million members right around where we told you we expected to be after navigating sign-ups, payments and effectuation. Consistent with our original guidance, we expect a little attrition throughout the remainder of the year, ending 2026 a little over 3 million members. Consolidated adjusted SG&A expense ratio was 7.6% in the first quarter compared to 7.9% last year, reflecting continued discipline and product mix. We ended the quarter with $437 million of cash available for general corporate use. During the first quarter of 2026, the company sold $1 billion of our stand-alone 2025 Part D risk share receivables and proceeds were used to repurchase $1 billion of senior notes that when coupled with strong Q1 earnings, resulted in a debt-to-cap ratio of 43.2%, down from 46.5% at year-end. Medical claims liability totaled $20.6 billion and represents 48 days in claims payable, an increase of 2 days as compared to the fourth quarter of 2025. As we look ahead, due to seasonal PDP sloping and the 2026 proportion of PDP to the total company, we would expect this faster completing business to drive down DCP a day or two as the year progresses. Cash flow provided by operations was $4.4 billion for Q1, primarily driven by strong net earnings, partial 2025 CMS PDP receivable sale and timing of other net payments and receipts. As we look to the rest of 2026, we are pleased to increase full year adjusted EPS guidance to greater than $3.40. In the press release table, you can see we added $1 billion of premium revenue to our prior range, largely driven by Texas Medicaid. We expect overall Medicaid membership to be down about 6% from year-end to year-end. We continue to be on track and expect the Medicaid composite rate yield around 4.5%. We also adjusted our consolidated SG&A guidance range down by 10 basis points and added $50 million to expected investment income, and no change to our HBR full year range of 90.9% to 91.7%. One final topic: within finance, we are deploying advanced analytics and selective AI-enabled tools across forecasting, medical economics and payment integrity. Today, these capabilities are used as an independent validation layer alongside our traditional forecasting process, bringing more timely data into how we evaluate emerging medical trend. Also helping us identify fraud, waste and abnormal claims behavior earlier, supporting better prioritization of resources and more disciplined cost management on behalf of state and federal taxpayers. We are pleased with a great start to 2026 and look forward to continuing to drive the margin recovery opportunity. Thank you for your interest in Centene and Rocco, we can open it up for questions.

I wanted to follow up on the higher acuity in the ACA Silver tier. Can you help us understand why you believe you attracted that higher acuity cohort for this year? And it sounds like you're currently accruing for a partial risk adjustment offset and 3% pretax margins. If you did ultimately get the full risk adjustment offset, what sort of margin would that imply for the full ACA year?

Yes, thanks, Andrew. So let me sort of take a step back and anchor on the biggest thing that changed in 2026 for everybody, which is really the expiration of the enhanced APTCs, and thanks to the new Wakely report with earlier data, we can confirm that that drove a significant number of consumers out of the market. It also, as we've seen, drove a shift across the market from Silver membership into Bronze products as consumers looked for more affordable plans. And so as a result, the Silver tier remaining membership really follows the golden rule of risk pools that when it strengthens, it becomes more and more concentrated in higher acuity members. And so given our market size, our Silver footprint and, frankly, our intentional decision not to go as hard on aggressive pricing strategy, which we still very much stand by, we were positioned to retain and attract more Silver members who are now more acute in that overall post-APTC environment. Now important to note that in other insurance markets, the concept of adverse selection can be scary, but that's not actually the case in Marketplace because, as you know, the risk adjustment mechanism is specifically designed to counteract adverse selection. And often, it can actually be a profitable strategy to care for sicker members in this market. And that's really based on our view, with more than a decade of experience in the market. So as we think about the additional visibility that we have since March by virtue of the Wakely data, which has really confirmed that unlike last year, the market is behaving the way we would expect in a number of cases, actually favorable to our expectations, and then the additional quarter of claims experience for our paid membership where we're seeing those risk scores year-over-year track directly in line with the claims experience that we observed. That gives us confidence in the view that we have a higher acuity Silver membership that will attract and get a risk adjustment receivable. As you heard from both my remarks and Drew's, we have not accounted for the full range of what that receivable could be in the updated guidance, but that range does wrap around our original 4% target margin for 2026 in Marketplace and frankly, higher than that at the top end. And so bottom line, we believe that what we've incorporated into guidance is a prudent posture for now in advance of getting the June Wakely data, and we still feel very good about delivering meaningful margin improvement for the business in 2026.

So I think coming into the year, you basically in Medicaid were forecasting a cost trend of about 4.5%, mid-4s and the rate updates being at 4.5%. It sounds like the rate updates are coming in consistent. The maybe the MLR in Medicaid is trending a little better. Is that primarily due to the flu and weather that you're calling out? Or are you seeing underlying performance improved there? And does that put you on a glide path if the trend is a little better versus the rate updates to get back to sort of a target margin for Medicaid next year?

Yes, thanks, A.J. So you're right. We came into the year with an assumption of a flat HBR year-over-year and really, the idea that rate in that mid 4.5% will be matched by net trend, which is obviously overall trend netted against our medical cost initiatives of 4.5%. We obviously saw a better performance in Q1. A bigger piece of that was flu, a little bit of weather, but there was still fundamental solid outperformance on Medicaid HBR driven by the business. And that really is a result of that consistent multi-tenant program that we've deployed over the last 1.5 years and pulling levers around network optimization, further scaling clinical programs, obviously, all the work we're doing around payment integrity and fraud, waste and abuse. We're also seeing increasing momentum from states around program changes and starting to see states even more receptive. We've called out a number of examples of those in the past, whether it be around formulary management or clarifying some of the benefits. We're now seeing states start to directly intervene on providers themselves around fraud, waste and abuse. And so those conversations are continuing to roll forward. So very pleased with the idea that part of the outperformance in Medicaid in the quarter was driven by delivering on the planned initiatives and also the fact that some of that pipeline of 2026 additional initiatives developed a little bit earlier than expected. Obviously, in the forecast for the rest of the year, we're not betting or counting on that outperformance to continue, but given the fundamental drivers of that, it obviously leans positive. And that would mean that we would come in at HBR, call it, 15 or 20 basis points ahead of that 93.7%. As you heard me say before, I would be disappointed if we didn't beat 93.7% given where we stand today; I will reiterate that I will be disappointed if that's all we can do. As we look ahead to 2027, our goal is to continue to drive margin improvement forward. And we obviously have work requirements and a number of policy changes that we're looking ahead to. But as we are strengthening the core operations of the business, we are doing that with a mind to and a goal to continue to drive progressive margin improvement through 2027.

Just a couple of follow-ups. One, you talked to the exchanges, and you talked about booking a receivable on risk adjustment, not just to the magnitude that you think it might actually come in. Is that true for the whole book or just for the Silver business? And then you gave us margins on Medicaid and exchanges, which we appreciate. Can you give us the same on Part D and Medicare Advantage in terms of margins, where you see them now versus coming into the year?

Sure. So first, you are correct that we moved our position to expecting a slight receivable in Marketplace. That is across the whole book because it is, as you know, just important to remember that risk adjustment is agnostic of metal tier. And so it takes into account the relative acuity of the population that you enroll regardless of where they sit between Silver, Bronze and Gold. So that receivable accounts for the entire population. And again, we did not book the full amount that the data suggests with that range, both wrapping around our original target margin and outpacing that, frankly. And then in Medicare, again, we're not reflecting continued outperformance in quarters 2, 3 and 4 in either PDP or Medicare Advantage, but as Drew and I both talked to, the fundamental drivers of those make us feel very good about the trajectory of those businesses. And so that would suggest that both of those segment margins for the full year would come in slightly better.

I want to focus on the balance sheet. It looks like you paid off about $1 billion of senior notes that were due in 2027 by selling some receivables. And based on our calculation, you have another $1.2 billion due in 2027, and another $2.3 billion in 2028. So just for modeling purposes, should we assume that you'll have to refinance that at higher rates? Or do you hope to pay some of that debt down?

Yes. Good question, Ann, thanks for paying attention to the balance sheet, like we do. So yes, we're acutely aware that we've got some maturities coming up in December 2027 and then the summer of '28. And so we would look to refinance those or maybe to your point, part of those at least a year out or so as we prepare for sort of rolling those into additional senior notes. So we're taking a look at our cash position which has improved quite a bit in the last 6 to 12 months, not just because of the PDP receivable sale. And we still have, as you can read in the last K and the Q, sort of the ability to sell more of that '25 receivable. But ultimately, we'll collect that, we think, no later than October from CMS. And then as we establish, let's say, a new receivable for the 2026 year, if that's where we end up in that position, then we'll think about that as well. So really pleased with the cash generation of the business. You saw that in the cash flow from operations this quarter. And we'll evaluate continued modification of debt balances. As we think about the volatility of this business over the last couple of years and think about what's the right debt load for the company to open up other avenues for deployment of capital.

I want to talk about rate development in Medicaid. I know the CMS rate development guide kind of alludes to the idea of work requirements. As we enter the back half of this year, states will be giving rate bases that may have to contemplate or could contemplate work requirements impacting the acuity of the valuation. How are you thinking about those discussions when you go talk to states? And I know we've got Nebraska kicking up work requirements—what have your state discussions looked like as we start full implementation of work requirements?

Yes. Thanks for the question. So you are right that we've got Nebraska that's going to kick off earlier than others, although they're a smaller state. And really, they're the only state that has pulled forward into 2026 so far. But given that we operate in that state, I think that will be instructive. As we step into rate conversations this year, we are, as you noted, very conscious of the fact that some of those member months will carry into 2027. And depending on the rate and pace with which states roll out or implement the work requirements, and obviously, CMS has given them some flexibility around that, there is a need to incorporate any anticipated acuity shifts into those rates. And so we're absolutely bringing that forward into the conversation. As I said earlier, those conversations continue to be constructive. When we think about the backward-looking experience, we are seeing more of 2025 data and the back half of 2024 data, which had that major acuity shift from redeterminations in it, and then the trend that we saw in 2025 really make their way into the base period. And so that's supportive of having rates that match overall acuity and trend. And then very appreciative, as you noted, of a really important set of guidance that CMS provided to states relative to when they come to seek certification on rates, being very explicit about how they have incorporated the impact of work requirements and what that might mean in terms of an acuity shift. So we think that is very helpful in terms of creating a level of consciousness and guardrail around that and sort of expectation management as those rates come up to CMS. There was also guidance around the fact that in these kinds of instances, mid-year adjustments and retros are also warranted. Broadly, what I think we are seeing is the system flex the muscles that we built during the redetermination process. And so again, increasingly, actuaries are not being hard tied to retro periods, but thinking about material program changes that may come and how they need to account for that. And then broadly, I would say that the flexibility that has been given to the states, the fact that this is on balance a smaller, more focused population, we're seeing states actually get really precise a lot earlier in the process. I was talking to one state in particular that has already run their frailty definition on their population, has a very clear view of what the at-risk pool is—actually probably smaller than you would expect—and already thinking hard about how to make sure that members who are eligible because they are correctly engaged or they are in that ex parte population get coverage and then how we support the others to find opportunities. So all of that, I think, gives us confidence. Now it's certainly a policy change and there's implementation and therefore, there is likely to be some degree of risk pool impact. But I think the way it's being rolled out is much more thoughtful, much more informed by data, much more aligned relative to our work, the state's work, CMS's work. And so I think that makes us look at 2027 and 2028 as something that we feel confident that we can manage through.

Kind of more of a modeling question, but just the quarterly progression in terms of MLR and earnings from here. I know there's some moving pieces in unknowns and some assumptions you're making in Marketplace as well. But what is your guidance right now on quarterly progression? Or can you give us anything in terms of that quarterly cadence around MLR and earnings that we should be embedding in the model given some of the mismatch in terms of relative to your expectations this quarter?

Thanks, Erin. So overall, EPS progression follows the same arc that we described coming into the year, but I'll let Drew go into a little bit more detail and then click down into the specific lines of business.

Yes, the EPS sloping, just like we said last quarter, we expect a step down in earnings from Q1 to Q2, still profitable. Q3 around breakeven and then Q4 at a loss position, given the seasonality of the business. And then maybe, more importantly, underneath that, what's driving that underlying sloping: in Medicaid, obviously, we had a good first quarter. We would expect Q2 and Q3 HBRs to be higher than Q1 and then Q1 and Q4 to be lower this year. Think about the traditional sloping of commercial businesses, including Marketplace, that's like a steady uptick of HBR throughout the year given benefit plan designs and seasonality of deductibles. Medicare similarly, largely driven by PDP, so you can see a steady march of HBR increase throughout the year. The slope line should be tilted a little bit higher this year just because of the mathematical impact of PDP being a larger proportion of the Medicare segment. So think about that as you're modeling the Medicare segment HBR throughout the rest of the year. And then SG&A, you go back multiple years, it's always the heaviest in Q4 given open enrollment and preparing for the 1/1 season. So that helps drive us into a loss position for Q4.

I've kind of an esoteric question, Sarah, which is as we think about your guys' initiatives in fraud, waste and abuse in particular, in ABA, when those issues get addressed they tend to come out of the rate from a state perspective. So actually fixing fraud, waste and abuse ends up being a headwind to rate from a state perspective. Is that something that you guys see? Is that a headwind that you guys navigate? And would just love to understand how those conversations go with your state counterparts.

Yes, absolutely. So I think there are probably two components to that. One is where we see excess use or fraudulent behavior. Unfortunately, we have seen a lot of that, both in terms of providers who were prescribing the maximum number of hours every single week for every single patient and frankly, other more fraudulent behaviors. Within that, there is a real opportunity to save taxpayer dollars and make sure that the fidelity of the rates that are in place for ABA are actually going to the right care. And similarly, making sure that whether with units per utilizer or the number of utilizers they are getting correctly prescribed the right therapy path and getting the right amount. A lot of what we've been focusing on is what I would call excess trend and then to your point, ultimately, if there is a tightening of the benefit design that would then allow for some degree of savings in rates. But I think we've got a ways to go before we get to that point. It's really making sure that the state is paying for the right therapy for the right members at the right level. And that's all good; that is exactly what we want to have happen. Our focus has been in that excess trend domain. And frankly, we're also seeing states take more direct action and intervention on some of these suspect or fraudulent ABA providers, not even relying on the MCOs but actually doing that directly because of an acknowledgment of the drag that that is creating on the system overall.

Another balance sheet question. It looks like the net payable for risk adjustment is up by over $300 million sequentially versus year-end. And I think you're obviously not speaking to a receivable position. So is that just more about how you booked Q1 versus how you're now thinking about the rest of the year in terms of guidance? And then if we think about basically the range around the potential upside and downside on the risk adjustment change that you're discussing in the potential benefit if it fully comes to a point estimate, is it right to think that the downside scenario, if you go back to the original assumption, is similar in terms of order of magnitude?

Yes, Stephen, no, an astute observation in the Q that we filed this morning. Yes, different thought process for what we actually book in the first quarter and waiting to see corroboration from the June Wakely data in terms of the accounting around that, which then informs our forecast. We forecast by year-end to be in that slight receivable position. So that's sort of the difference when you're evaluating that table in the Q. And then as Sarah said, in the range of upside and downside, yes, you're always thinking about what could swing either way in all of our businesses and feel pretty good about what we think is a cautious, prudent stance at a Marketplace margin around 3% pretax embedded in current guidance. And as Sarah said, to the extent we get the corroboration that the data supports, then that would present some degree of upside to that current guidance.

And I would just add, maybe specifically to the downside scenario: we feel like we've anchored in a conservative point and that the downside would not be going back to the meaningful payable assumption that went into the initial guidance for the year, because I think that was embedded in the question. So our posture is cautious but positioned to capture upside as data corroborates.

I wanted to come back to the fraud, waste and abuse topic, and a follow-up to George's question. We've heard some consultants suggest that fraud targets in state rate development can actually create a 'go get' for the plans in terms of savings that you need within the rate development. I wonder if you see any of that, Sarah. And then same topic, but in the Marketplace, are you expecting any additional program integrity measures applicable in 2027 that were not applicable in 2026?

If I take a big step back on fraud, waste and abuse, we haven't explicitly seen the dynamic you're describing where states hold back on rate and say you can make up the difference through fraud savings. Frankly, we wouldn't be against that—the idea that states would let us operate more fully against our mandate to preserve program integrity. There are many places where we are limited relative to how we would like to operate, and where we could preserve benefits and member experience while saving taxpayer dollars. That's a dialogue we'd be open to. We feel like this is a place where we have really focused: we have 30 states' worth of data that we aggregate not just to look at best practices, but to find fraudulent providers who hang out a shingle and then get kicked out in one state and show up in another. We uniquely have an ability to get ahead of that. Drew talked about that in his remarks as well in terms of where we're deploying AI and daily algorithms to detect suspect behavior. So again, I do think there is opportunity for program reform that doesn't necessarily create a rate headwind, but creates overall margin improvement opportunity and stronger program integrity for our state partners. Then relative to Marketplace, we are seeing a cleaner membership base as a result of the program integrity measures that went into place last year and those that rolled into this year. Some of those measures are stayed pending litigation, and that court case may see some resolution as we get through the summer; it may not. It's possible that some of those measures roll forward into 2027, and we're taking that into account as we think about 2027 pricing and any additional impact on the membership base and the risk pool.

I wanted to dig in a little bit more to some of the comments about Medicaid. You said you were seeing pockets of deceleration in some areas of trends. Could you talk a little bit more about that? Also, what are you seeing around acuity? There's been a lot of risk pool shifts on the Medicaid side and some of your competitors are talking about stabilization. How are you thinking about how the risk pool has been trending the last few quarters?

Absolutely. We've talked about behavioral health, home health and high-cost drugs as three of the top trend drivers for over a year now. Behavioral health has been and continues to be the primary driver. We go deep and look at how we think trend is evolving in each of those areas—whether that be a PMPM impact, overall utilizers, or units per utilizer depending on the domain. As we look across that cohort, we are seeing some pockets of deceleration, particularly around units per utilizer in the behavioral health space. That is probably partly an indicator that states are getting more sophisticated about defining the benefit and the provider community is getting stronger in terms of articulating evidence-based guidelines, in strong partnership with the work we're doing. ABA is a subset of that, and you heard me talk about the fact that we are seeing stabilization in that trend. Those trends are still elevated from past years, but we are seeing a year-over-year relative stabilization that we believe is a direct result of the actions we've taken over the past year. We're not seeing continued year-over-year steps that we saw over the last couple of years, and we believe our actions are having an impact. From an acuity standpoint, last year we talked about overall trend roughly 6.5%. Embedded in that was an assumption of continued attrition in the member base based on redetermination and the corresponding acuity shift. As we looked at 2026, similarly embedded in the net 4.5% trend assumption is an ongoing view of quarterly attrition for that redetermination work and any risk pool shift that goes along with that.

A couple of questions on Medicaid. Can you talk a little bit about the net trend impact—looking at utilization management and network management efforts—and what the impact of those is that brings you from gross to net? Within that, is there a component of state benefit design changes and can you quantify that? And as you're interacting with states, what are they focusing on from an RFP perspective and pipeline perspective in terms of new business or how they're responding to federal pressures?

Thanks. Let me take those in reverse order. On RFPs, after the bolus of RFP catch-up post-COVID, 2026 is a quieter year. Only a small number of larger states are in or planning an RFP process. We're starting to see states better align the RFP process for different programs, which can be a good thing—Indiana, for example, will reprocure their program all at once rather than off-cycle. That alignment gives us an opportunity because of our strength in core programs to expand membership through those processes. We're also seeing states consider whether this is an opportunity to move additional higher acuity cohorts into managed care because of budget pressures from policy changes and economic factors, so there's growing interest in stable cost management through managed care. Relative to net trend, we haven't quantified the exact delta from gross to net in the call, but the levers are consistent: network optimization, clinical programs, payment integrity, and fraud, waste and abuse activities. Those collectively drive us down toward that net 4.5% assumption. As you saw in Q1, we had outperformance versus that assumption and we have a strong pipeline of initiatives for the rest of the year, which gives us confidence in our ambition to outperform current run rates. There are also places where states are leaning into program changes that don't necessarily require rate increases, but do allow clearer benefit design and let MCOs apply data-driven approaches to procure the highest quality, lowest-cost care on behalf of the state, which ultimately improves margin profile and reduces pressure to raise rates further.

If I put together the moving pieces on HBR total company—Medicaid, Medicare, the rest of the year, Marketplace up 100 bps—it kind of implies that Medicare in Q1 beat your expectations by about 370 basis points. Is that the right way to think about it? Or did your consolidated HBR move within the range? And then I get that there's a program change between '25 and '26, but the implied slope on Part D and blended Medicare is significant. It looks like it's 1,100 basis points. Can you give us a little bit more detail on your confidence that the slope will be so steep on Part D HBR?

Good questions. Let me take them in reverse order. Yes, the sloping of our Medicare segment HBR should be steeper this year, but that's really a function of PDP being a higher proportion of the segment—about $25 billion of revenue. We have historical data going back to 2006 that informs the impact of benefit changes and how to slope PDP results throughout the year, so I feel good about our start to the year in PDP. That parlays into the Medicare segment HBR as a whole. There was a beat in Q1, not to the extreme of your calculation, but we are pleased with both Medicare Advantage and PDP contributing to outperformance in Q1. As Sarah said, we assume a return toward previous assumptions in Q2–Q4, although we will continue to drive both businesses to outperform current guidance where possible.

On Part D, can you drill into the LIS versus non-LIS mix and what you saw in the first quarter? We've been tracking variation in specialty pharmacy spending trends between LIS and non-LIS since the IRA. Are you seeing convergence between the two around spending trends, or are they still divergent? And how do you view the risk model recognition of that dynamic?

Good questions relative to our PDP business. We're about one-third in our basic product, which is largely the low-income subsidy (LIS), about one-third in LIS and about two-thirds in the enhanced product which is largely non-LIS. You're right: the IRA affected behaviors differently in the non-LIS population versus the LIS population, which has long been protected with different cost exposures. Those trends continue to be very high in non-LIS—members taking advantage of the $2,000 maximum out-of-pocket and manufacturers pricing behavior has influenced that. The good news is we saw that dynamic in 2025 and managed through it, still producing pretax margin in the 3s, and we used that data to set bids and forecasts for 2026 assuming a continuation of high non-LIS specialty trend. That's reflected in our forecast and our bids. It's still a high absolute number, just not as high as what we had assumed in our forecast. Regarding the risk model, the calibration is based on pre-IRA claims data so it doesn't capture the full effect yet. That suggested model change to accelerate recognition of IRA impacts was not adopted for the 2027 risk model; therefore, we expect direct subsidy pressure to go up again as we think about 2027. Overall, good 2026 performance so far, optimistic about continuing to deliver on PDP, and we believe we're well prepared for 2027.

Thanks, Rocco, and thank you all for joining us this morning and for your interest in Centene. We are out of the gate in 2026 with solid momentum, and we look forward to updating you on how the business progresses over the coming months. My Centene colleagues, thank you for setting the tone. I'm excited to see what we can deliver for our members, our customers and our shareholders this year and going forward. Thank you all.