Good morning, and welcome to the Molina Healthcare Fourth Q uarter 2020 Earnings Conference Call. Please note this event is being recorded. I would like to turn the conference over to Julie Trudell, Senior Vice President of Investor Relations at Molina Healthcare. Please go ahead.
Good morning. Welcome to Molina Healthcare's fourth quarter 2020 earnings call. Joining me today are Molina's President and CEO, Joe Zubretsk y, our current CFO, Tom Tran, who is retiring later this month, and our current Head of Transformation and Corporate Development, and CFO elect, Mark Keim. A press release announcing our fourth quarter earnings was distributed after the market closed yesterday and is available on our investor relations website. Shortly after the conclusion of this call, a replay will be available for 30 days. The numbers to access the replay are in the earnings release. For those who listen to the rebroadcast of this presentation, we remind you that the remarks made herein are as of today, Thursday, February 11th, 2021, and have not been updated subsequent to the initial earnings call. In this call, we will refer to certain non-GAAP measures.
A reconciliation of these measures with the most directly comparable GAAP measures can be found in our fourth quarter 2020 press release. During our call, we will be making forward-looking statements, including, but not limited to, statements regarding the COVID-19 pandemic, the current environment, recent acquisitions, 2021 guidance, and our longer-term outlook. Listeners are cautioned that all of our forward-looking statements are subject to certain risks and uncertainties that can cause our actual results to differ materially from our current expectations. We advise listeners to review the risk factors discussed in our Form 10-K annual report for the 2019 year filed with the SEC, as well as the risk factors listed in our Form 10-Q and our Form 8-K filings with the SEC. After the completion of our prepared remarks, we will open up the call and take your questions.
I would now like to turn the call over to our Chief Executive Officer, Joe Zubretsky. Joe?
Thank you, Julie, and good morning. Today, we will provide updates on several topics. First, we will cover enterprise-wide financial results for the fourth quarter and full year 2020. Second, we will provide initial earnings and earnings per share guidance for 2021. Lastly, we will conclude with some thoughts on our compelling strategic position and our future growth prospects. Let me start with the fourth quarter highlights. Last night, we reported GAAP earnings per diluted share for the fourth quarter of $0.56, with net income of $34 million and total revenue of $5.2 billion, a revenue increase of 22% over the prior year. On a normalized basis, defined as adjusted earnings per share and excluding the net effect of COVID, our earnings per diluted share were $3.29 for the fourth quarter.
This is consistent with our performance in the first three quarters of 2020, each of which produced approximately $3 per share after adjusting for the effect of COVID. Two items significantly impacted the earnings in the fourth quarter. The first, and most prominent of these items, was the net effect of COVID, which decreased net income in the quarter by $3.80 per share. The most significant contributor to this impact was the continuation of rate refunds already in flight and the introduction in the quarter of COVID-related retroactive rate actions in California, Michigan, and Ohio. These refunds, taken together, more than offset the net effect of modest utilization curtailment and a high level of COVID direct cost of care. The second significant item having an impact in the quarter came from adjustments that produced a combined net benefit of $1.07 in earnings per share.
The most significant of these was a net benefit from the proceeds of federal litigation, which was partially offset by a charitable contribution to our foundation. In summary, we are pleased with our normalized fourth quarter performance with respect to both the continued delivery of solid earnings and the focused execution of our growth strategy. All of this was achieved while dealing with the effects of the global pandemic. Now, turning to the full year. We reported full year 2020 GAAP earnings per diluted share of $11.23, with net income of $673 million and a 3.5% after-tax margin. We generated premium revenue of $18.3 billion, an increase of 13% over 2019, reflecting increased membership. We ended the year with four million managed care members, a 700,000 member increase year-over-year, primarily due to growth in Medicaid.
Our Medicaid enrollment finished the year strong at 3.6 million members, representing growth of over 640,000 members or 22% over the prior year. This increase reflects strong organic growth of 450,000 members or 15%, as the suspension of redeterminations was the major catalyst for our Medicaid membership growth in 2020. Growth of 370,000 members related to the acquisitions of YourCare, which closed on July 1st, and Passport, which closed on September 1st. This organic and inorganic growth was offset by the 180,000 member decline related to our planned exit from Puerto Rico. I will now provide additional color on our full year normalized financial performance, which better expresses the underlying strength of our business by isolating the transitory effects of COVID and adjustments. On a normalized basis, our earnings per diluted share were $12.97 for the full year.
Our normalized performance comfortably exceeded our full year guidance of $11.20-$11.70 per share, which was established in the absence of COVID, and is therefore the most relevant comparison. With respect to medical margins for the full year, our MCR on a normalized basis was 85.9%, compared to 85.8% in the prior year. In Medicaid and Medicare, our performance met expectations, while in Marketplace our performance was below our expectations. Our normalized G&A ratio for the year was 7.3%, compared to 7.7% in 2019, reflecting disciplined cost management and the benefits of scale produced by our substantial growth. We produced a normalized after-tax margin of 3.9%, despite our Marketplace business underperforming. We are very pleased that while dealing with the medical cost distortions and operational complexity caused by the pandemic, we produced a normalized margin consistent with our long-term target.
Now, I will comment on the item by item effects of COVID on our full year 2020 results. The net effect of COVID decreased pre-tax income by approximately $180 million, or $2.30 per share. This result is the sum of several identifiable positive and negative factors as follows. For the full year, the net benefit from COVID related utilization curtailment, offset by direct care related to COVID patients, was approximately $420 million on a pre-tax basis. I should note that while utilization was moderately curtailed in both the fourth quarter and the full year, in the fourth quarter, direct COVID medical costs were higher than in any other quarter of the year. For the year, COVID related risk sharing corridors reduced premium revenue and earnings by approximately $565 million on a pre-tax basis.
$400 million of this amount was reported in the fourth quarter, as the three new COVID-related risk sharing corridors were enacted, and the corridors already existing at the end of the third quarter remained in effect. For the year, COVID-related activities increased our G&A spend by approximately $35 million on a pre-tax basis. Without question, the effects of COVID created significant distortions to our 2020 operating metrics. The underlying operating fundamentals and financial metrics remained strong. Turning to our 2021 guidance, beginning with premium revenue. We are very pleased with the rapid activation of our growth strategy. In 2021, we project premium revenue of at least $23 billion, a 25% increase over 2020. This growth is well balanced between a new contract win, organic growth, bolt-on acquisitions, benefit expansions in our existing geographies, and greater penetration of our Medicare and Marketplace products into our Medicaid footprint.
More specifically, our premium revenue guidance includes a full year of the acquired Magellan Complete Care businesses, which we closed on December 31st. A full year of Kentucky revenue, which commenced on September 1st, 2020. A full year of revenue from the YourCare membership in upstate New York, which we assumed on July 1st, 2020. Marketplace revenue growth of 25%-30% as we begin this year with more than 500,000 members. The full year carve-in of the pharmacy benefit in the state of Washington, which is somewhat offset by partial year pharmacy carve-outs in New York and California. The revenue decrease associated with our planned exit from Puerto Rico. The impact of the Affinity acquisition is not included in our premium revenue guidance.
We expect the transaction to close as early as the second quarter. The acquisition could provide $600 million or more in additional premium revenue in 2021. Our guidance includes membership growth relating to the current Public Health Emergency extension set to end in mid-April 2021, with a steady decline over the remainder of the year as redetermination is activated. The Biden administration has recently indicated that it is likely the Public Health Emergency will remain in place for the entirety of the year. If so, states could continue to receive the additional 6.2% FMAP match throughout 2021, which would likewise extend the redetermination suspension requirement for the state. Although we have been adding more than 100,000 Medicaid members per quarter during the redetermination suspension in 2020, it is unclear whether this pattern would continue should the PHE be extended further.
Therefore, we have not included in our guidance an estimate of revenue associated with additional volume from potential PHE extensions. However, any extension of the PHE, accompanied by redetermination suspension, could certainly represent upside to our 2021 revenue outlook. We estimate that for every month the redetermination suspension is extended past April, it could provide additional revenue of approximately $150 million per month. Turning now to earnings guidance. Given our recent and expected continued M&A activity, adjusted earnings per share has become a more relevant measure of our earnings going forward and will be the focus of our comments today. Our initial full year 2021 adjusted earnings guidance is in the range of $12.50-$13 per share, or approximately 20% growth from 2020 adjusted earnings of $10.67 per share. The upper end of our 2021 guidance range is essentially equal to our 2020 normalized earnings per share of $12.97.
Our 2021 earnings profile reflects durable and sustainable operating improvements and earnings growth, which are being temporarily muted by ephemeral industry-wide challenges. Specifically, our 2021 earnings guidance reflects the following positive long-term value drivers. Continued strong performance in Medicaid and Medicare, reflecting an actuarially sound base rate environment. Margin recovery and growth in our Marketplace business, which we target to achieve mid-single-digit pre-tax margins for 2021 as a result of our intense focus on operational improvements and continued competitive prices in product designs. Accretion from the Magellan Complete Care businesses and our Kentucky and Passport installation. Our earnings guidance also considers the following industry-wide environmental challenges, including another net negative impact from COVID, although at a reduced level, due to the continuation of many of the risk-sharing corridors that existed in 2020 and the direct costs of COVID-related patient care, offset by moderate utilization curtailment.
Lower than expected Medicare risk scores, which are an industry-wide challenge that will pressure results. Our risk scores do not fully reflect the acuity of our membership, as in 2020, seniors reduced their access to healthcare services, and therefore, risk score capture was more challenging. Referencing these catalysts and challenges, we now quantify the progression from our 2020 normalized earnings of $12.97 per share to the midpoint of our 2021 adjusted earnings guidance of $12.75 per share. We expect strong core performance to contribute approximately $1.25 in adjusted earnings per share growth, emerging mostly from Marketplace, as Medicaid and Medicare margins are near optimal. Accretion from our acquisitions, along with share repurchases, will positively impact adjusted earnings by approximately $1 per share. Offsetting these positive factors are two industry-wide environmental challenges that temporarily pressure earnings.
Specifically, we expect the net effect of COVID, consisting of utilization curtailment and direct cost of care, offset by risk-sharing corridors, to continue to negatively impact earnings, but in 2021, by approximately $1.50 per share. The temporary Medicare risk score shortfall phenomenon will pressure results by approximately $1 per share. All of these items, when combined with the initial performance of recent acquisitions operating below target margins, impact our 2021 MCR by approximately 200 basis points when compared to 2020 normalized. This corresponds to a 90 basis point impact on the net income margin. Our 2021 guidance represents solid underlying earnings growth, but it is a constrained picture of the embedded earnings power of the company.
The financial profile that we can develop when COVID and industry-related headwinds abate, and when our acquisitions achieve their full run rate potential would include, first, the net effect of COVID and the Medicare risk score disruption have created approximately $2.50 of adjusted earnings per share overhang. We would expect this overhang to disappear as COVID abates. Second, once we attain our targeted margins on Magellan Complete Care and Kentucky, and once Affinity is closed and synergized, we would expect to achieve additional adjusted earnings per share of at least $1.50. In short, our pro forma run rate after the natural relaxation of these temporary constraints would produce an after-tax margin of approximately 4%, which is in line with our recent performance, and produce adjusted earnings per share comfortably in the mid-teens. I will now provide a few concluding comments that frame the compelling strategic position we have created.
The execution of our margin sustainability and revenue growth strategy has allowed us to create a very attractive financial profile. Despite all of the near-term distortions caused by COVID, the achievement of our 2021 guidance implies generating EBITDA of $1.2 billion with adjusted EBITDA margins in excess of 5%. Producing a return on equity of nearly 40%, which is a function of our attractive margin position and disciplined deployment of growth capital. Projecting contribution margin upside as we soon expect to achieve our target margins in our acquired businesses. Generating excess cash flow, which when combined with leverage, gives us the continued ability to acquire businesses in our core. Producing a two-year compound annual growth rate of 20%. To summarize, with the durable earnings catalysts being sustained and as the temporary earnings challenges dissipate, our operating profile would produce mid-teens earnings per share.
Despite the challenges and near-term distortions caused by the global pandemic, our confidence in the growth, earnings power, and resilience of our business remains high. The inherent growth characteristics of these businesses are exceptionally strong, and we will execute and harvest growth through winning new states, growing market share in our existing states, increasing penetration in high acuity populations, and actioning accretive acquisitions in our core business. We will continue to sustain best-in-class operating metrics and margins, drive top line growth, and remain relentlessly focused on our value-creating mission. I will note that despite the vicissitudes of the economy and despite the pandemic, our management team and our associates have demonstrated a tenacity, a determination, and an ability to deliver. We are in the right businesses with the right people at the right time. Our future is very bright.
With that, I will turn the call over to Tom Tran for some additional color on the financials. Tom?
Thank you, Joe. Good morning, everyone. I am going to discuss our balance sheet, cash flow, and 2021 outlook. Operating cash flow for the full year 2020 was $1.9 billion, reflecting the strong operating result, growth in membership, and the timing of government receipts and payments. Our reserve approach remains consistent with prior quarters, and our reserve positions remain strong. Days in claim payable at the end of the quarter represent 50 days of medical cost expense, compared to 52 days in the third quarter of 2020 and 50 days in the fourth quarter of 2019. Prior years reserve development in the fourth quarter of 2020 was modestly favorable and was negligible in the comparable period in 2019. We extract $280 million of subsidiary dividends in the quarter and $635 million year to date.
The parent company cash balance at December 31, 2020, was $644 million, a decrease from the prior quarter cash balance of approximately $1.3 billion, due primarily to the cash outlay for the Magellan Complete Care acquisition. As of December 31, 2020, our health plans had total statutory capital and surplus of approximately $2 billion, which equates to approximately 330% of risk-based capital. Through December 31, 2020, we repurchased an aggregate of approximately 760,000 share for $159 million, at an average price of approximately $208 per share. We continue to reduce our cost of capital. In November 2020, we closed on a private offering of $650 million senior notes due November 2030, and used a portion of the proceeds to repay the $330 million senior notes. Debt at the end of the quarter is 2.1x trailing 12-month EBITDA. Our leverage ratio is 53%.
However, on a net debt basis, net of parent company cash, the leverage ratio is 45%. Taken together, these metrics reflect a reasonably conservative leverage position. Turning to guidance. We introduce our initial full year 2021 adjusted earnings per share guidance range of $12.50 to $13. We expect premium revenue to exceed $23 billion, a greater than 25% increase over 2020. Total revenue is expected to exceed $24 billion. We expect the medical care ratio to be approximately 88%. The MCR increase over 2020 is primarily due to the continuing net effect of COVID, temporary Medicare risk score disruption, and higher MCR from recent acquisitions. We expect our adjusted G&A ratio to improve to approximately 7%. This reflects continued disciplined cost management, revenue growth, and fixed cost leverage. The tax rate is expected to be approximately 25.6%.
Adjusted after-tax margin is expected to be approximately 3%, which is impacted by approximately 90 basis points relating to the items I just mentioned, including the continuing net effect of COVID, Medicare risk scores, and initial performance of recent acquisition operating below target margins. This concludes our prepared remarks. Operator, we are now ready to take questions.
We will now begin the question and answer session. To ask a question, you may press star then one on your touch-tone phone. If you are using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw your question, please press star then two. At this time, we will pause momentarily to assemble our roster. Our first question comes from Matt Borsch with BMO Capital Markets. Please go ahead.
Yes. Good morning. I was hoping you could just talk a little bit about the coming, sorry, Marketplace special enrollment period, and how you expect that to impact you, when you take into consideration what you've characterized as underperformance in 2020.
Sure, Matt. Our forecast for membership in the Marketplace, starting the year with 500,000, ending the year with just under 400,000, didn't contemplate the special enrollment period. We're certainly aware of it. We certainly have forecasts of what it could provide. For those 90 days, it could provide anywhere from 20,000-30,000 additional members. We're forecasting that potentially it could provide an extra $100 million-$150 million of revenue for the year. Now, in the context of our margin recovery process, it's unaffected by that. We're very comfortable with the pricing we put into the Marketplace. We're very comfortable with our product designs and our benefit designs and our product positioning. We're very comfortable in achieving our mid-single-digit pre-tax margins for the year, irrespective of any additional revenue attained through the special enrollment period.
Maybe just related to that, how much do you think the competitive environment in the Marketplace impacts your efforts to get to the mid-single digit level?
It is very competitive. There's lots of new entrants. We're very confident, and one of the reasons we're confident is the two areas of operational letdown, if you will, in 2020, utilization review, and attainment of risk scores. We have introduced operational excellence of those two operating fundamentals in our other two businesses. We're really good at it in Medicaid and really good at it in Medicare, and we were just behind in importing those skills that exist in our company to the Marketplace platform. That has been corrected, we're very comfortable that by executing across those two fundamentals, we'll get back to mid-single digit margins.
Yeah. Thank you.
Our next question comes from Ricky Goldwasser with Morgan Stanley. Please go ahead.
Yeah. Hi, good morning. A couple of questions here. Just thinking about the one-time items in 2021, just to clarify, as we think about 2022, what can we exclude from the sort of temporary one-time headwinds as we think about the starting point for next year? It seems just the COVID cost has a number of moving parts in it.
Sure. During our prepared remarks, we gave a sort of a qualitative bridge in understanding the catalysts and pressures inside our 2021 guidance, all with the goal of helping our investors understand what might be looked at as a jumping off point into 2022. Here are the puts and takes. First of all, the net effect of COVID of $1.50 per share or $110 million of pre-tax will dissipate over time. As utilization comes back to normal, as the risk orders disappear, that $1.50 overhang will evaporate as the pandemic is solved. In addition, the Medicare risk score phenomenon. Last year was an interesting year. Seniors didn't access healthcare, interacting with them, getting the right codes to attain the right risk scores was a challenge, not just for us, but for many of our competitors.
Next year, we will either attain the risk scores, because they'll be getting services, or if we aren't satisfied that we can, we can include that in our bids. Last year, obviously, the bids were done far before the impact of COVID was ever known. We're very comfortable that combined, that $2.50 overhang sort of disappears as COVID gets behind us. As we said, in addition, our acquisitions are being integrated really well, and we're very comfortable with the $1 of accretion that we're putting in this year's guidance. We're also comfortable in saying that when they hit their full target margin and when Affinity is closed and hit its target margin, there's an additional $1.50 of earnings per share there. All in, there's a good $4 of earnings per share embedded power sitting inside our 2021 guidance.
Just to follow up, when we think about the acquisitions, I mean, clearly, you've done multiple acquisitions in 2020. How should we think about sort of management bandwidth to continue to do acquisitions in 2021? Should we think about you taking a pause this year, making sure that they're all integrated, getting to the target margin, and then coming back to the market?
We have created the bandwidth. We have an expert M&A team that finds the properties and knows how to action them and close them. We built a world-class integration team. The Passport integration is going really well, and the early read on the Magellan integration is going really, really well. That's why we're so comfortable in affirming the accretion targets that we've given you. They've actually, very fortunately, laid out quite nicely on a timeline. By the time Magellan is fully integrated, we'll just be closing on Affinity, perhaps by the second quarter. If we action one, two, or who knows how many more this year, and they close either late in the year or early next year, the timeline couldn't be more amenable to being very effective at integrating them and harvesting the accretion that we promise our investors.
Thank you.
Thank you.
Our next question comes from Robert Jones with Goldman Sachs. Please go ahead.
Great. Thanks for the questions. I guess maybe just two on the bridge, and appreciate you guys breaking out a lot of these components. It looks like the core growth off of that 2020 baseline of $12.97 would be somewhere in the 9.5% range. I'm not sure how much of the HIF benefit would be flowing through, but obviously that's below the long-term target of 12%-15%. Just wanted to see if you could maybe walk through some of the moving pieces here and, probably more importantly, how you're thinking about the timeline to get back into that long-term range of 12%-15%.
I want to make sure I understand your question. Are you talking about the puts and takes within our 2021 guidance or beyond?
Yeah. Sorry, Joe. Just in 2021, it seems like if you look at the core growth that you've laid out in these slides of $1.25 on top of-
Sure.
$12.97, obviously that'd be below the long-term targets. Just curious if you could talk through?
Sure.
Kind of getting back towards that range. Obviously it sounds like there's some tailwinds that are not necessarily baked in yet, which I'm sure would be helpful. Yeah, just wanted to get your thoughts on the growth you've laid out here at the core versus getting back to the long-term range.
Sure. Well, bear in mind that the core performance here is irrespective of the net effect of COVID, which is tracked in a different place as the way we've articulated this. The $1.25 is mostly the Marketplace, since that was the business that underperformed last year. It was just about break even in 2020. We're targeting mid-single digit pre-tax. If you look at the potential for $1.9 billion-$2 billion of revenue, you can start to formulate a picture of how that is a significant contributor to the $1.25 core performance tailwind into this year. There are some puts and takes in there, but with Medicare and Medicaid margins where they are, we're going to grow the top line and attain the margin position there is, but there's not a lot of margin upside in Medicare and Medicaid.
We're very comfortable with the position that we've presented here from a core business perspective. Medicare and Medicaid are pretty much optimized with respect to margins, but Marketplace, as a first step to getting back to where we said we would be, a mid-single-digit pre-tax margin would be our target for 2021.
No, that's super helpful. I guess just one follow-up on the bridge, the $1 you have here for acquisitions and repos. If I remember, I think you guys had called out $0.50-$0.75 expected from Magellan. Sounded like YourCare and maybe the Puerto Rico exit would roughly net out. $0.40 for repo, and I think Passport would be the other swing factor. I guess first, does that math make sense as far as trying to bridge to that $1?
Yeah.
How should we think about the split between repo and Passport to make up that $0.40 balance?
Yeah, you're generally in the right area. If I were to break apart the $1, I would say that $0.75 is Magellan, which is the top end of the range that we committed to for the first full year of ownership. $0.10 on Kentucky. It'd be very close to break even in the first full year of ownership, and we'll drive it to peak margins after that. About $0.15 on buyback. That's how you get to the $1.
Super helpful. Thanks, Joe.
Okay, thank you.
Our next question comes from Charles Rhyee with Cowen. Please go ahead.
Oh yeah, hi. Thanks for taking the question. Joe, just wanted to follow up, just to clarify one other thing. I apologize if I missed that. When we talk about the net effect of COVID in the $1.50, is that pulling out all the effect of COVID, even for acquisitions? I guess the question is, in your assumptions for accretion here in 2021 for something like Kentucky, are you factoring in the impact of COVID for Passport within the acquisition bucket, or is it all in the COVID bucket?
We've attempted to capture all COVID impacts in the COVID line item. Just to sort of reframe how we track that. Our estimate of COVID impact is the amount of medical cost suppression we believe we've observed, offset by the direct cost of caring for COVID patients. Then, of course, both offset by the impact of any liabilities generated due to the retroactive rate refunds or corridors. That's how we capture it. If it related to an acquisition, it's captured in the COVID line.
Okay. Thank you. Just a quick follow-up. In Kentucky and Passport, do we have a sense yet on timing for when they are going to do sort of the auto-enrollment, so you'll know what your sort of membership numbers look like?
In Kentucky, the open enrollment period was extended to March 15th. There's still members moving around. We began the year with 320,000 members. The latest accounting has us about in that same zone. On March 15th, the period will shut down, and we'll know how many members that we're beginning our new contract with.
Okay, great. Thank you.
Our next question comes from Gary Taylor with JP Morgan. Please go ahead.
Hey, good morning, Joe. I just wanted to make sure I understand what you're saying about your reverification assumption. When we look at, for example, the bridge between 20 and 21, that $1.25 of core growth, you're saying most of that is from exchanges. If you're anticipating at this moment that you're still going to have reverifications in mid-year start to take place and some of your Medicaid enrollment rolling off, I'm presuming there's a net negative number embedded in there. Is that the right way to think about it? I just want to make sure you're suggesting if that doesn't happen this year, whatever that embedded negative number is, that comes back. Can you size that for us?
Sure. It's interesting because it's all about your assumption of how fast membership rolls will attrit once the states turn redetermination back on. I will tell you, in our numbers, the way the membership flows, both in 2020 and in 2021, there is actually a member month increase in 2021, just based on the timing of both acquisitions and redetermination. No, I would say that the redetermination process is literally 100% upside to our revenue and earnings picture in the year. We just felt it wasn't prudent, nor did we have any credible way of estimating how many more members we would get if the redetermination pause was extended, and then how fast would they actually roll off, depending on how states plan to implement the reintroduction of redetermination.
I would just say that the redetermination issue or phenomenon is upside to both our revenue and earnings guidance for the year.
You've still got enrollment growth playing out now through the first half, some assumptions about some leakage in the second half, but that weighted average is still positive year-over-year?
Yes.
Got it.
The way we look at it is, on a Medicaid basis, we're beginning the year with 3.6 million members. On January 1st, 200,000 members come over due to MCC. In the first quarter, based on our historical average of about 30,000 a month during redetermination suspension, we pull in another 100,000 members. It would hit its peak at 3.9 million, 600,000 would roll off in the balance of the year. That's a pretty quick roll-off, and it might happen slower, which is another perhaps element of conservatism in our forecast. Yes, if you then process that against 2020 and the timing of how membership grew and the timing of our acquisitions, there's actually a 9% member month growth in 2021 on Medicaid.
Very helpful. Thank you.
Thank you.
Our next question comes from Justin Lake with Wolfe Research. Please go ahead.
Thanks. Good morning. A couple questions here. First, Joe, a lot of people at JPMorgan got the impression that the COVID headwind was going to be materially less than the $2. I'm curious if there's something that happened between then and now to push that number up closer to $2. You did a great job of kind of laying out for us the 2020 components within the COVID headwind. Can you do the same for 2021 and specifically on utilization? Can you tell us where you expect COVID costs to be versus normal utilization? Thanks.
Sure. Let's provide the context for 2020. Our estimate of medical cost suppression for the entire year was about $620 million. That was offset by approximately $200 million of the direct cost of COVID care for COVID patients, netting to a $420 million surplus. We hesitate to call it a benefit, a surplus, due to the impact on medical costs from the COVID pandemic. We then, this is not an estimate, it's an actual number, recorded $565 million of rate refunds, risk-sharing corridor liabilities in the year. That, combined with additional G&A of $35 million, resulted in the net $180 million pre-tax cost of COVID in our company for the year, which is $2.30 a share. Juxtaposed against that, to answer now your direct question, we are forecasting a more moderate, more modest level of suppression.
The reason is both the supply and demand side of the healthcare economy were shut down last year for a while. Patients were afraid to go in for services, and if they wanted them, there were many executive orders and direct mandates not to provide elective and discretionary procedures. The supply side is open for business this year, but we still think there'll be a demand-side softening, and will result in utilization suppression of somewhere around $200 million for the year, which is one-third of the amount of suppression we experienced in 2020. We'll incur direct costs of COVID care, and the net of all that is somewhere between $140 million and $150 million. Most of this, we forecast, will happen in the first half of the year.
Hopefully, the vaccinations and the vaccine, and social distancing will cause all this to really dissipate in the latter half of the year. Against that, we're also forecasting approximately $250 million of impact from retroactive, or not retroactive, but risk-sharing corridors, I should say, which nets to about $100 million, $110 million, which is your $1.50 a share. The gross numbers are a lot less dramatic, but it's still netting to $1.50 a share. One of the reasons we're very comfortable with this estimate is really we focus on the net impact, because if utilization is higher or lower than expected, there'll be some flex up and down with the risk-sharing corridors. There's actually sort of a natural hedge between the suppression and the corridors themselves. We look at the net number. We're very comfortable with that net number.
As the pandemic goes away, we think this goes back to normal times, there'll be no impact from COVID on a going-forward basis, obviously. I hope that helps. That's the tale of the tape. I know that was pretty detailed, that's what's included in our $1.50 estimate for the cost of COVID for 2021.
Joe, that's really helpful. Just so what you're saying here effectively is you've got a $110 million risk corridor hole where they're just setting your margins lower than your typical target. That's really the problem. The other stuff's going to flex up and down, but you're below target here by $110 million.
Yeah.
Do all of your states at this point have risk corridors? Is there any uncertainty around more of them coming on?
Well, let me address the first part. The answer to the first part, the response is, yes, that's true. If you're already in a risk corridor and your medical costs go up or down, there's no net impact on the company. That is the way to look at it. Because the risk-sharing corridors didn't address COVID suppression specifically, it just addressed your MLR. If you're outperforming your MLR targets, you're giving back some money to the state.
Right.
The intention was to have a direct correlation between COVID suppression in a corridor, but the corridor is against medical costs generally. The fact that we're very profitable in some states, the fact that we outperform many of the market participants in some states, the rate refund number's probably a little higher than people might have expected. The answer to your second part of your question is correct. It will flex up and down in a state where we're already in a corridor, and where a state where there's not, we would either enjoy the benefits of additional surplus or the effects of additional higher medical costs. The biggest state that does not have a corridor in 2021 is California. Texas and Washington already had them, and all of our other states continued them on into 2021.
Thanks.
Our next question comes from Scott Fidel with Stephens. Please go ahead.
Hi. Thanks, Chad. Good morning. First question, Joe, I wanted to talk a little conceptually about the long-term margin target. It looks like you gave us a crosswalk back to that 4% level that you had been guiding for as the long-term view for the last couple of years. Just interested though, and maybe taking the other side of that a bit, just in terms of comfort with that, longer term, just when we think about the exchange margin profile, you have rebate effects. Since your Investor Day a couple of years ago, you guys are doing more inorganic growth, acquiring lower margin businesses. There is a consistent mix impact that will likely-
Yes.
be from that. Also just if some of these risk corridor programs, the states end up liking them a bit, right, and end up keeping them. Just wanted to just get your thoughts on sort of framing some of those maybe longer term headwinds against that 4% long-term target.
Sure, Scott. As we sit here in the second year of this global pandemic, we're not going to update our long-term margin guidance. We're just sort of going to go as you go, as you plow through this, start to form your views of what the landscape is looking like as you plow through it. I think that's the more prudent approach. Having said that, when you actually look at the pro forma impacts of many of these phenomenon that we consider quite temporary, you can pro forma this thing back to the high threes or close to 4%. To the second part of your question, I actually hope that we always have a decrement sitting inside our margin for acquisitions that do not perform in their first year.
That's a good decrement to have because if we can buy properties that are underperforming and with sweat equity, get them to perform, that is just another form of accretion. The 40 basis points. There's 40 basis points in our margin in 2021 in our guidance that is literally related to the underperformance in the first year of our acquired properties, both on the G&A line and on the MCR line. The last part of your question was related to the risk corridors. Look, when they were introduced in 2020, they were clearly related to the pandemic. They were presented that way. They were retroactive because they had to be, because they were introduced mostly after the pandemic started. As they were reintroduced for 2021, they were presented as pandemic related.
The feeling was that there could be strange effects from the pandemic, additional COVID costs, the cost of the vaccine, additional suppression. That's why they were introduced on a symmetrical basis. You're protected on the downside. The state's protected on the upside. In CMS's approval guidelines, they have clearly stipulated that when they receive these for approval, they are viewing these as being attributed to the utilization impacts related to the pandemic. It's been pretty clear to us that they were presented as related to the pandemic. CMS is approving them on the basis of relating to the pandemic. We believe when the pandemic dissipates, that these will disappear as well. We'll be back to the traditional rate setting environment where rates are set prospectively using a credible medical cost baseline and a trend off that baseline.
Got it. For my follow-up question, I know a lot of this content has just come out in the last day or two, and you guys are probably absorbing it, but just interested, Joe, in sort of your framing on some of the proposals that came out of Ways and Means on expanding the HIX subsidies and from E&C on some of the Medicaid expansion proposals and how you would frame the opportunity from that. I guess also caveated with that, because they're using reconciliation, the funding for it is only temporary for two years. I guess there would be questions on sustainability, right, of the funding if, for example, the Republicans took back either the House or the Senate in 2022.
Thanks for that question. We're only three weeks into the new government. Look what's been done. We all knew that the new government would be proponents of the social safety net, of making sure the disadvantaged have access to high-quality healthcare, plenty of subsidies. They can afford it. Look what's happened just in the first three weeks. In terms of the executive order, at least the intention to extend the PHE to the end of the year, the executive order to introduce the special enrollment period on the Marketplace. The euphemism in the executive order was encouraging states to look at prior administration policies, which was really taking a shot at the public charge rule and Medicaid work requirements. Just what's come out of the White House in the past three weeks is incredibly bullish on government-sponsored healthcare, particularly for the disadvantaged.
To your other point, things can get done through the reconciliation process, and they're going to. The three committees in the House that generally write to healthcare issues are Ways and Means, Energy and Commerce, and Oversight. Look at the language that they're introducing. Increasing subsidies in the Marketplace up to 150% of FPL, making the product accessible to people over 400%, capping the cost at 8.5% of their income, and so on and so on and so on. Just in three weeks of a new government, both in the legislative bills that are coming out of the House and from executive order in the White House, just couldn't be better for government-sponsored managed care. We're pleased to see that progress already being made.
Okay. Thanks.
Our next question comes from Dave Windley with Jefferies. Please go ahead.
Hi. Thanks for taking my questions. Joe, good morning. I wanted to follow on Gary's line of questioning on the redetermination. Last time around, when that was turned back on, there was kind of this realization that the risk profile or the margin on those folks redetermined off was pretty attractive, maybe even included a lot of zero utilizers. I'm wondering if you think that is likely to happen this time around when that finally gets turned back on, and have you made that assumption in your guidance or in your estimates?
The answer to your last part of your question, Dave, is no, we haven't. It still remains to be seen what it does to the acuity of the population. Now, because we haven't introduced many more members in our forecast, so our guidance only includes 100,000 member growth in the first quarter of the year, and then the attrition starts in the last three quarters of the year. We certainly have not forecasted a continued softening of the acuity profile of our membership base. In fact, if that happens and it happens in a quarter state, it'll go back against the quarters anyway. Net-net, the impact of the extension of the redetermination suspension is a net positive. On any dimension, it's a net positive to our guidance. We did not include any members past the first quarter. We rolled them off pretty quickly.
As I said in my prepared remarks, if you take 500,000 members, which is sort of what we got in redetermination, for every month at $300 PMPM, there's your $150 million of additional revenue. What's the margin profile of that revenue? You could speculate that it's very good as the acuity of the population improves as you get more members. We have not included any of that impact in our guidance for the year, either the membership flow or a acuity improvement that is sort of a positive jolt to our earnings and earnings per share.
Okay. Follow up, separate topic. As you think about, to your comments earlier on having built the bandwidth and the integration team to continue to look at M&A, as you look at targets, does a thought around the balance of how you'd like to build your book of business influence what you're looking at, i.e., increasing MA and, well, really MA, I guess, from an acquisition standpoint, in your mix, or is it more opportunistic and what looks the best? How do you think about the balance of your book as it relates to inorganic growth?
We'd love to balance it out with more Medicare. They're hard to find, but we'd love to balance out with more Medicare. We're growing it nicely organically, but we'd love to find properties that have Medicare Advantage or D-SNP populations. I would say along the lines you've asked the question, we more look to the state. Is it a bolt-on to the state where we don't have so much market share that we couldn't get it done? Lighting up new states, really important. High acuity, really important. We're really good at high acuity, and there's a lot of players out there that have a lot of high acuity lives and have little ability to manage them. The upside on $1,500 of premium per month is huge. Huge margin potential. I would actually say that the geography's important.
We love high acuity, and if they're underperforming but not broken, all the better, because then we'll take our operating team, open up the Molina playbook, and drive accretion through margin expansion.
Great. Thank you.
Our next question comes from Kevin Fischbeck with Bank of America. Please go ahead.
Great. Thanks. Just wanted to make sure that I understood it. We've talked a lot about redeterminations this year, I guess in theory, it is a headwind in 2022 guidance. It's not something that you guys spiked out as something that would be contrary to that $4 of earnings power. I wasn't sure if that was included in your net COVID number when you thought about 2022, or that's something that we should separately identify. If it is separate, are there any other kind of factors we should take into account?
No, since we did not put any impact, if there is a positive impact from redetermination in 2021, since it's not in our guidance, we did not then therefore create a headwind in 2022. Just to be very clear, because I appreciate the question, any impact from the extension beyond April of any additional membership or a slower attrition of membership is not in our revenue guidance, and any profit enjoyed by additional member months in 2021 is not in our guidance. As I said, we're very comfortable saying there's only upside to 2021 on the redetermination suspension.
Well, I'm talking about what's in 2021 in your guidance, because you have it going through April and then slowly coming off as the year goes on. To your point about member months, you'll end the year at your Medicaid enrollment number, but your member months in 2021 will be higher than your 2022 member months, just because redetermination's in for the first full quarter and partially rolling off as the year goes on.
Sure. I understand your question now. Sorry, I apologize. I misunderstood your question. Again, we weren't giving a specific 2022 outlook. We were more trying to craft the bridge that we gave you as, if we're guiding to $13 a share for 2021, sitting inside that is an earnings power that's higher than $13 due to some temporary phenomenon. We weren't necessarily trying to extend into 2022 with an earnings or a revenue bridge. Sorry, I misunderstood your initial question, that will come at a later date.
Okay. That is something else we should factor in to think about earnings power.
Sure, unless the suspension goes on and members stay on through the end of 2021, depending on other acquisitions that we might do, then there's the Affinity piece that's coming in. We're not doing a 2022 guidance bridge per se, but I understand your question and it's a legitimate one.
Okay, maybe just a second question. The Exchanges, it's obviously unusual to see a company grow very quickly and expand margins the way that you guys did. Obviously sounds like risk coding is part of it. How should we think about that business? Is 2021 guidance normalized margin? How do you think about long-term, the top-line growth outlook for Exchanges?
We're going to be guarded in giving a forecast for where the margins will land. The competitive landscape changes every day. We're very comfortable in getting this to mid-single digit pre-tax this year. Our hope, again, given the competitive landscape, that would lead to mid-single digit after tax in the future. That's where we think the business could perform. Let's work through the 2021. There's a lot of revenue to bring on, a lot of members to service. Some of them are new. We'll have to get their risk scores. Let's one step at a time. I've asked my team, let's get to the mid-single digit pre-tax margin this year, and then as we prepare our bids for 2022, let's sort through how much margin we think we can get and how much membership we think we can get.
Starting the year with 500,000 and a 25%-30% revenue growth year-over-year was a nice start to get back in the game in this business.
Great. All right, thanks.
Okay. Thank you.
Our next question comes from Josh Raskin with Nephron Research. Please go ahead.
Thanks. Good morning. Question on the Medicare risk score headwind of the $1 per share. I sort of calculate that to about 3% of your total Medicare revenues, which seems a little bit higher than I think what some others are suggesting. I guess my question would be, how much of your overall Medicare premium dollar actually comes from risk adjusters? Are there any actions you're taking sort of shorter term to try and improve that risk scoring this year as you sort of get ready for next year and to the bids in the middle of the year?
Yeah, Josh, truth be told, in that dollar is a little bit from the physician fee schedule. We just didn't think it was that big enough to call out. There's a little bit of physician fee schedule in there. You're in the right zone. 2.5%-3%. Our risk score revenue is multiples of that, two to three times that at least, from what I recall. The industry had a choice last year. We're in the middle of a pandemic, it just started in March and April. You're now starting to develop your bids. For the most part, while we always tend to be conservative in our bids, we didn't put in a specific load for, okay, we're going to fall short on risk scores. Obviously, with hindsight, that cost us three points on the revenue line.
Next year, meaning this year, we'll either have an estimate of what we think we can attain, and then based on what we target for benefit design and our margins, we would then allow for that in the bid we submit. Either way, whether we get the risk score or whether we price to it, we think this is a one-year phenomenon. That's the way we look at it.
Okay. All right, it could be as much as a third to even half of your total risk score revenues disappearing this year. That's sort of the math, right?
I think it's about a third. I will check that, but I think it's about a third.
Okay. Just quick follow-up on your margins. Where did you end 2020 full-year margins in Medicaid and Medicare?
Where did we end? Well, again, depending on whether you look at a normalized basis or not. On adjusted earnings for 2020, we're at 3.3% net income margin, normalized 3.9%. I would tell you that the individual margins for the lines of business were generally in line with our long-term targets. 3.3% adjusted, 3.9% normalized. The lines of business, except for Marketplace, obviously, which was close to breakeven, were pretty much in line.
Perfect.
Our next question comes from George Hill with Deutsche Bank. Please go ahead. Pardon me, George, your line might be muted.
It was. Thank you for that. I'm sorry, Joe, as it relates to the Medicare risk scoring, I guess, can you talk about the timing or your expectations as it relates to the ability to conduct the beneficiary evaluations and maybe talk about what you've seen in the back half of 2020 and kind of the expectations as we roll through 2021, just as your ability to get in front of these people?
Sure. Well, utilization did remain suppressed through the balance of 2020. It wasn't as suppressed late in the year. Look, our team is on this. We have a crackerjack Medicare team. They are all over this, and their instructions are very simple. Have a credible estimate of how many interactions you can actually achieve. What's your reasonable estimate of proper risk scores attained? To the extent it falls short of your long-term expectation, make sure you consider it in your bid. Either way, and obviously with the goal of making sure your product remains competitive with benefit designs from competitors. The team's all over it. The good news is this year we'll have full visibility. Last year it was the fog of war, and you're submitting your bids right as the pandemic was in full throttle.
We made the conscious decision not to introduce that into our bid. This year, we would think otherwise.
Okay. Thank you.
This concludes your question and answer session. I would like to turn the conference back over to Joseph Zubretsky for any closing remarks.
Thank you, operator. When we started this transformational journey over three years ago, the work ahead loomed pretty large. We knew that if we formed the right team, that we could succeed. We sought to recruit managed care industry veterans, battle-hardened veterans, if you will, who would know exactly what to do. Tom Tran personifies that. He developed a durable financial infrastructure that has been instrumental in our early success and which will have lasting impact. The team he built is a high-performing one, and we are very confident in their continued success. Tom's tireless energy, steady hand, and good nature will certainly be missed by us all. Tom on behalf of all of our constituents and from me personally, thank you for your immense contribution to our success, and we wish you the best of luck and good health in your retirement.
Operator, with that, we'll end our call today.
The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.