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Earnings Call Analysis

Strong Earnings Growth Amid Medicaid and Investment Challenges

Elevance Health reported strong second-quarter results, with adjusted diluted earnings per share growing 12% to $10.12. Despite challenges in their Medicaid segment and ongoing investments in CarelonRx, they reaffirmed their full-year earnings guidance of at least $37.20 per share. Commercial membership grew significantly, especially in individual ACA plans, while Medicaid redeterminations led to increased acuity among members. Carelon Services saw a 26% surge in operating revenue. The company's disciplined approach lays a solid foundation for sustainable long-term growth.

Strong Earnings Growth Amid Dynamic Environment

Elevance Health reported robust second-quarter results, with adjusted diluted earnings per share (EPS) reaching $10.12, a significant 12% growth year-over-year. This strong performance underscores the company's successful execution amidst a challenging and dynamic operating landscape. The company reaffirmed its full-year adjusted EPS guidance of at least $37.20, also representing a 12% year-over-year growth.

Strategic Initiatives and Business Transformation

Elevance Health continues to invest in business transformation and capability enhancement, particularly within its CarelonRx segment. These investments are crucial for the company’s ongoing evolution and its ability to deliver sustained growth. Despite the industry-wide challenges in the Medicaid business, Elevance Health remains optimistic due to new business wins and successful reprocurement efforts, particularly with programs like the Indiana PathWays for Aging.

Balanced Performance Across Health Benefits

The Health Benefits segment demonstrated resilience and balance, with notable membership growth, especially in the individual ACA business which has expanded substantially year-over-year. The segment is also benefiting from high retention levels and strong customer acquisition in national accounts. Consolidating business with existing employer group clients highlights the unique value Elevance Health offers.

Challenges and Opportunities in Medicaid

Medicaid saw new business successes and strategic wins with programs like Indiana PathWays and the KanCare Kansas Medicaid RFP. However, Medicaid membership attrition and acuity increases have posed challenges. The company is proactively working with states to ensure sound actuarial rates and anticipates increased utilization in the second half of the year.

Carelon Services and Rx: Driving Future Growth

Carelon Services reported a remarkable 26% growth in operating revenue and a more than 30% increase in operating earnings. This growth is attributed to risk-based service expansion and effective pricing strategies. CarelonRx also promises substantial growth opportunities as it continues to integrate acquisitions like Paragon Healthcare and plans for the pending addition of the Kroger Specialty Pharmacy business.

Financial Performance and Projections

For the second quarter, Elevance Health recorded total operating revenue of $43.2 billion, flat year-over-year. The benefit expense ratio was 86.3%, an improvement driven by premium rate adjustments and disciplined medical management. Despite increased investment costs, the company's operating expense ratio is expected to improve significantly in the latter half of the year. Elevance Health's financial outlook remains strong, with a continued focus on disciplined underwriting and operating efficiency.

Commitment to Long-Term Growth

The company’s growth algorithm aims for an average annual adjusted diluted EPS growth of at least 12%, supported by upper single-digit revenue growth. Elevance Health is focused on margin improvement and capital deployment to achieve these targets, leveraging geographic expansion, and membership growth. The strategic importance of CarelonRx and Carelon Services as growth drivers remains a key focus area for the company.

Earnings Call Transcript 2024-Q2

[Operator]

Ladies and gentlemen, thank you for standing by, and welcome to the Elevance Health Second Quarter Earnings Conference Call. [Operator Instructions] As a reminder, today's conference is being recorded.

I would now like to turn the conference over to the company's management. Please go ahead.

[Stephen Tanal, executive]

Good morning, and welcome to Elevance Health's Second Quarter 2024 Earnings Call. This is Steve Tanal, Vice President of Investor Relations. And with us this morning on the earnings call are Gail Boudreaux, President and CEO; Mark Kaye, our CFO; Pete Haytaian, President of Carelon; Morgan Kendrick, President of our Commercial Health Benefits business; and Felicia Norwood, President of our Government Health Benefits business.

Gail will begin the call with a brief discussion of the quarter and recent progress against our strategic initiatives. Mark will then discuss our financial results and outlook in greater detail. After our prepared remarks, the team will be available for Q&A.

During the call, we will reference certain non-GAAP measures. Reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are available on our website, elevancehealth.com.

We will also be making some forward-looking statements on this call. Listeners are cautioned that these statements are subject to certain risks and uncertainties, many of which are difficult to predict and generally beyond the control of Elevance Health. These risks and uncertainties can cause actual results to differ materially from our current expectations. We advise listeners to carefully review the risk factors discussed in today's press release and in our quarterly filings with the SEC.

I will now turn the call over to Gail.

[Gail Boudreaux, executive]

Thank you, Steve, and good morning, everyone. We appreciate you joining today's earnings call. This morning, we reported second quarter results, including adjusted diluted earnings per share of $10.12, reflecting 12% growth year-on-year. These results reflect thoughtful execution in a dynamic operating environment as well as the unique strengths of our enterprise, including the power of our diverse set of businesses.

We have reaffirmed our full year adjusted diluted earnings per share guidance of at least $37.20, which represents 12% growth year-over-year. We have prudently maintained our full year outlook given industry-wide dynamics we are navigating in our Medicaid business and the investments we are making to support business transformation and deepening capabilities within CarelonRx.

Our Health Benefits segment demonstrated balance and resilience in the quarter. In commercial, we continue to make progress on our margin recovery initiative and are delivering solid membership growth, notably in our individual ACA business, which has grown substantially year-over-year. We've also extended our momentum in national accounts, where the business is tracking to historically high retention levels and new customer acquisition remains strong.

Year to date, we've consolidated business with additional existing employer group clients who previously only worked with us on a slice of their business, a testament to the unique value we deliver to the market.

In Medicaid, we are pleased with our recent new business wins and reprocurement success, positioning us for future growth. We launched the Indiana PathWays for Aging Program just weeks ago and are proud to be the largest payer in this important program in our home state, serving nearly 40% of all eligible Hoosiers. Indiana PathWays plays directly to our strengths, serving populations with chronic and complex needs. We were also privileged to be awarded the KanCare Kansas Medicaid RFP this quarter, working in partnership alongside two Blue partners as Healthy Blue.

Turning to Medicaid redeterminations. While nearly all of our members have had their eligibility redetermined since the products resumed last year, our work is not done. With approximately 70% of coverage losses attributable to administrative challenges, we continue our proactive outreach to members to maximize access to care and minimize barriers to whole health. We expect disenrolled members to enroll throughout the year, albeit on a longer lag than expected when redeterminations resumed last year.

We are seeing the percentage of returners steadily increase, especially in our Blue states, where we offer both commercial and Medicaid health plans. As a result of redeterminations, our Medicaid membership mix has shifted, resulting in increased acuity, and we are working actively with our state partners to ensure rates remain actuarially sound.

In Medicare, we were pleased with the recent ruling regarding our challenge of the initial 2020 Star ratings. As a result, our enterprise weighted average rating has increased to 4 Star. And we now expect approximately 56% of members will be in plans rated at least 4 Star or in contracts too new to be rated that will be reimbursed similarly in payment year 2025.

This outcome will help offset funding cuts to the Medicare Advantage program for the second consecutive year, which we believe will result in increased premiums and/or reduced benefits for seniors and people with disabilities who rely on Medicare Advantage for their health and well-being. For our part, we maintained our disciplined approach to 2025 bids. We will be offering highly valued and competitive benefits as we seek to balance growth and margins and remain focused on building an attractive and sustainable Medicare Advantage business for the long term.

In our health services businesses, we are making progress on our key strategic priorities to scale our enterprise flywheel for growth. Carelon Services delivered robust growth in operating revenue and earnings in the quarter as we gained traction with external clients, both through new business wins and the expansion of risk-based services to existing customers.

For example, we recently secured a significant win with an existing Blue Cross Blue Shield partner and deployed new behavioral and medical benefit management services to state and third-party payer clients. These awards are a testament to the value we deliver and an affirmation of our strategy of proving value internally before driving growth externally.

Turning to CarelonRx. We are integrating recent acquisitions and scaling key value drivers as we invest to control the levers that matter to deliver greater value and enhance consumer experiences to our members. Our margin performance in the second quarter reflects elevated investment, specifically around infrastructure and service levels, as we remain committed to providing best-in-class home delivery and specialty Rx services. We see significant opportunity to grow and scale these assets and remain excited about the growth potential of CarelonRx.

We are making progress on our enterprise strategy in 2024: To accelerate capabilities and services, invest in high-growth opportunities and optimize our Health Benefits business, and have robust long-term growth potential embedded in each of these imperatives.

We are delivering strong and accelerating growth in Carelon Services with a long runway ahead. Meanwhile, our guidance for 2024 embeds significant investment in growth, notably in CarelonRx and government health plan operating margins below the long-term average with meaningful upside to our targets.

Our focused execution reflects our confidence in Carelon as our flywheel for enterprise growth and the embedded earnings power of our businesses, which together will enable us to deliver strong growth in adjusted diluted earnings per share over the long term.

In closing, I want to thank community partners who share our purpose and dedication as well as our associates who work hard every day to make Elevance Health a lifetime trusted health partner to the members we are privileged to serve. Their collective passion is reflecting a recent external recognition, including as one of America's Greatest Workplaces in 2024 by Newsweek, where Elevance Health earned 5 out of 5 stars, as well as our inclusion among the Best Companies to Work For, for 2024 by U.S. News and World Report.

With that, I'd like to turn the call over to our CFO, Mark Kaye, to discuss our financial results and outlook in greater detail. Mark?

[Mark Kaye, executive]

Thank you, Gail, and good morning to everyone on the line. As Gail shared, we reported second quarter results, including GAAP diluted earnings per share of $9.85 and adjusted diluted earnings per share of $10.12, representing growth of 12% year-over-year.

We ended the second quarter with 45.8 million members, principally reflecting attrition in our Medicaid membership. Our commercial fee-based business grew by 354,000 lives year-over-year, reflecting the distinct value we provide to self-insured employers and the strength of the Blue Cross Blue Shield brand. Additionally, the thoughtful positioning of our individual ACA products has proven effective in ensuring robust and profitable growth.

Total operating revenue for the quarter was $43.2 billion, approximately flat year-over-year. As we approach the tail end of Medicaid redeterminations, we anticipate growing operating revenue in the second half of the year, driven by growth in premiums and CarelonRx product revenue related to higher external membership and the acquisition of Paragon Healthcare.

Carelon Services momentum accelerated in the quarter. Operating revenue grew by over 26% and operating earnings increased by more than 30% due to growth in risk-based services provided to internal and external clients, prudent pricing and strong execution.

The consolidated benefit expense ratio was 86.3% for the second quarter, an improvement of 10 basis points year-over-year. This improvement was driven by several factors, including premium rate adjustments and recognition of medical cost trends, disciplined medical management and a shift in our mix of business towards commercial. This was partially offset by our Medicaid business where acuity has increased due to attrition of healthier members.

Elevance Health adjusted operating expense ratio was 11.5% in the second quarter, an increase of 50 basis points relative to the second quarter of 2023. We absorbed elevated investment costs, notably in CarelonRx. And this, along with other strategic initiatives, will position our company for long-term sustainable growth. We anticipate significant improvement in our operating expense ratio in the second half of this year. Adjusted operating gain for the enterprise grew approximately 6% year-over-year, led by Carelon Services.

We have maintained a prudent posture with respect to reserves. Days in claims payable at the end of the second quarter stood at 45.3 days, above our long-term target range in the low 40s. As a reminder, days in claims payable in the first quarter included approximately 1.7 days related to the industry-wide delays in claims receipts.

With respect to our outlook, we are closely monitoring acuity and cost trends, notably in Medicaid, and are working collaboratively with states to ensure rates remain actuarially sound. We are however expecting second half utilization to increase in Medicaid, and as a result, anticipate our full year benefit expense ratio in the year in the upper half of our initial guidance range. Nonetheless, we expect to achieve our full year adjusted diluted earnings per share guidance of at least $37.20.

Before I close, I'd like to briefly talk through our enterprise growth algorithm which we have included in the supplemental earnings presentation provided this morning. Our commitment to growing adjusted diluted earnings per share by at least 12% annually, on average, incorporates upper single-digit growth in operating revenue, underpinned by membership growth, geographic expansion, and momentum in Carelon as we scale our enterprise flywheel.

Our commitment to disciplined underwriting and operating expense management across all lines of business will drive the improvement inherent in our enterprise operating margin target of 6.5% to 7% by 2027. Taken together, we are targeting growing operating earnings in the upper single-digit to low double-digit percent range annually on average over time. Finally, we expect capital deployment to consistently deliver 1/3 of our targeted adjusted diluted earnings per share growth rate.

Overall, our results in the first half of the year are consistent with our initial guidance, and we will maintain a steadfast focus on execution and operating efficiency over the balance of the year.

And with that, operator, please open the call to questions.

[Operator]

[Operator Instructions] For our first question, we'll go to the line of A.J. Rice from UBS.

[Albert Rice, analyst]

Maybe just to kick it off here. I know you've laid out your long-term growth objectives and all. I wonder if it's this early date, you're prepared to comment a little more on any plans you have to accelerate growth in '25. I know the top line has had redeterminations and other things this year. What's your thought about ability to get back to that growth trajectory, just thinking long term in '25?

[Gail Boudreaux, executive]

Thanks, A.J., and thanks very much for the question this morning. I think let me start with what Mark outlined as our enterprise growth algorithm because I think that really frames for everyone how we are thinking about our business. And also, as you think about 2024 and our results, the balance and resilience of our complementary businesses, that has allowed us to grow in multiple ways in many types of different macroeconomic environments.

While it is early for '25, I'd like to at least frame sort of how we're thinking about 2025. We do expect to accelerate revenue growth across all of our businesses. Specifically in our health business, we see a lot of really strong momentum in commercial, and that's been ongoing. Part of that's through the targeted expansion of our individual ACA footprint, and in some cases, adding new geographies that help support what's happening in the Medicaid redeterminations.

The Medicare Advantage, as we said in our opening comments, we feel that we've positioned ourselves through sustainable growth and margins and look at that as a very good long-term business. And in Medicaid, we're nearing the end of the redetermination cycle and we do anticipate a return to growth. And you've heard about some of our early wins this year, which we are very pleased with. We also do believe that some of those were redetermined based on administrative reasons will be coming back, albeit it's taken a little bit longer than we originally thought.

And then I'd like to kind of close these comments about our excitement around Carelon and the growth that we're seeing and how we progressed. You saw some of that come through in the second quarter. In Carelon Services, we are seeing some very strong external growth in the quarter, and we see expanded opportunities as we continue to build our capabilities, particularly in the risk market. And what we're seeing here is our ability to prove it on our own businesses first and then take it to the market commercially has been a really strong selling point for us, and we're very excited about that.

And then finally, CarelonRx is our ability to scale especially on the specialty side, including the integration of some of our recent capabilities, such as Paragon Healthcare, BioPlus Specialty Pharmacy. And we're looking forward to adding the Kroger Specialty Pharmacy business as well as we continue to diversify.

So overall, as we think about acceleration of revenue growth in '25, we do expect it across all of our business and are extremely positive about what we're seeing inside of our business.

[Operator]

Next, we'll go to the line of Nathan Rich from Goldman Sachs.

[Nathan Rich, analyst]

I wanted to ask on Medicaid. I think about 1/4 of your book is due to set rates in the back half of the year. Could you maybe just talk about what your guidance assumes for these rate updates? And maybe anything you've seen kind of so far as you think about the updates for July or October to the extent you have visibility?

And I guess, Mark, on your comment on Medicaid utilization. Have you seen the level of care on a same member basis increase? Or is the issue really just the timing dynamic between where state rates are and the level of acuity that you're seeing in your population?

[Gail Boudreaux, executive]

Well, thanks for the questions, Nathan. A lot in there. So let me ask Felicia Norwood, who leads Government, first, and then have Mark respond to the second part of your question. Felicia?

[Felicia Norwood, executive]

Nathan, you are absolutely right about the way our rate timing works. We have about half of our states where we have rates in the first half of the year and the other half in the back half of the year, with a core group certainly in fourth quarter. At this point, we have visibility into nearly all of our Medicaid premium for 2024 and the rate conversations with our states are very constructive.

With that said, not all rates are final. We are in constant conversations with our states and providing them with information, updated information, that we see in terms of the experience almost weekly, to make sure that they are seeing what we are seeing from an overall change perspective as we wind down redeterminations, which certainly has been one of the largest transformative things that have happened in Medicaid for some period of time.

I will say that the conversations are ongoing. We fully expect our rates to remain actuarially sound. But we acknowledge the potential for a short-term disconnect between the timing of our rates and the emerging acuity in our populations, and that's certainly been reflected in our updates for the year.

I will say that we continue to make sure that states and their actuaries have the most recent data that we have. And we will continue to have that engagement as we go through the fourth quarter rate process with the few very large states that remain in negotiations with us.

And with that, I will turn it over to Mark to talk about the rest of the issues around utilization.

[Mark Kaye, executive]

Thanks very much, Felicia. Medicaid utilization in the quarter, as you heard from Felicia, reflected higher acuity as expected. We are also seeing signs of increased utilization across the broader Medicaid population, including in outpatient, home health, radiology, durable medical equipment, as well as some elective procedures.

I just wanted to add here. Just as we noted in our prepared remarks, the full year outlook does allow for both this shift in acuity and increased utilization in the second half of the year, including the rate timing mismatch that Felicia spoke to.

[Operator]

Next, we'll go to the line of Lance Wilkes from Bernstein.

[Lance Wilkes, analyst]

Could you talk a little bit about CarelonRx? And in particular, interested in the contracting approach and scope for the CVS contract that underlies parts of that as you're in-sourcing things? And then just if you could give a quick update on the status of the integration rollout, the Anthem members and other members of BioPlus and Paragon, and the status of Kroger.

[Gail Boudreaux, executive]

Great. Well, thanks, Lance. I'm going to ask Pete Haytaian, who leads Carelon, to address your questions.

[Peter Haytaian, executive]

Yes. Thanks a lot for the question, Lance. We feel very good about the overall strategy as it relates to the pharmacy. I'll start with how we're performing on the core and growth in the core.

Our strategy is resonating in the marketplace. There continues to be a lot of interest in what we're doing as it relates to the strategic levers that matter and how we're in-sourcing and diversifying our business. And I think our value story is really resonating -- integrated value story. And that's really playing through with highly competitive pricing. And again, we continue to perform very well on the core PBM down market and middle market. So we feel very good about that.

As it relates to our diversification and your question on our assets, things are going very well. As we talked about with regard to specialty, we spent the last year building out our infrastructure to be able to handle the capacity -- to have the capacity to handle the Elevance scripts. And we feel very good about that. We began to migrate scripts at the beginning of this year as it relates to specialty, and we continue to move forward in that regard.

And importantly, we are preparing right now and continue to make investments around the Kroger close and assuming those scripts as well. Right now, we're projecting that to close Q3, Q4 of this year. And again, a lot of preparation and investment to make sure that we do that really well.

And then finally, as it relates to Paragon, again, just to reiterate the opportunity there because we feel very, very good about that. We're talking about $16 billion of infusion spend as it relates to Elevance Health with about 50% of that being in the hospital setting. So again, a great opportunity for us to have care be provided in a more appropriate setting, be it in an ambulatory side or in the home. And we feel very good about our positioning and the density that we have in our markets as it relates to that.

And importantly, as part of that strategy, we are targeting, at a ZIP code level, the standup of ambulatory sites to be able to provide that care. We're launching one imminently, and then we are preparing and building out strategies to launch others into 2025.

So overall, we feel very good about our strategy of in-sourcing the strategic levers that matter and the growth opportunity that exists.

[Gail Boudreaux, executive]

Thanks, Pete, and thanks again, Lance, for the question. And just I think this is a great example of our flywheel for growth and our ability to scale these assets, which we're very excited about. And again, thinking about this as the opportunity to drive a differentiated cost of care for our health plans within Elevance Health, but also better experience for members and support our partners across the ecosystem. So again, a really important part of our flywheel.

[Operator]

Next, we'll go to the line of Kevin Fischbeck from Bank of America.

[Kevin Fischbeck, analyst]

I guess in your prepared remarks, you mentioned that the results here were somewhat burdened by, I guess, three things. One, investments in Carelon for growth, and then you had below-average margins in Medicaid and below-average margins and Medicare Advantage. Can you help size those things? How should we think about where those margins are today relative to kind of where they should be from a target perspective?

[Mark Kaye, executive]

Thanks very much for the question. We're not going to comment on in detail where our single line business operating margin may land given our combined Health Benefits reporting segment. But however, to your question, let me give you a little bit of color.

We do expect the Medicaid margins to compress year-over-year. There are key factors driving this, including or beyond the industry-wide dynamics that we're navigating. And those include what we spoke to a moment ago around the timing mismatch in rates relative to acuity and the higher acuity itself associated with the Medicaid membership mix. Importantly, as you heard us talk to just a moment ago, we are holding very constructive conversations with the states to ensure those rates remain actuarially sound.

In Medicare, we do continue to expect margins are going to improve in 2024 compared to 2023. They will still remain below our long-term target margin range. And then finally, we are very pleased with the progress of our 2024 commercial repricing initiatives and our disciplined pricing practices.

And we've spoken about this before, but it's worth emphasizing. 2023 really marked that first -- or the end of that first full year of our efforts to recover margins, and you're seeing some of that benefit together with the actions that we're taking in 2024, come through our numbers.

[Operator]

Next, we'll go to the line of Josh Raskin from Nephron Research.

[Joshua Raskin, analyst]

What are your expectations for market level growth in MA for 2025? And I know it's early, but maybe any headwinds, tailwinds, and how we should expect Elevance to grow market share relative to the overall market in MA for 2025?

[Gail Boudreaux, executive]

I'll ask Felicia to comment on that, Josh. Thank you.

[Felicia Norwood, executive]

Josh, thank you. It's an incredibly dynamic time in Medicare Advantage. And now more than ever, we think it's important to be very thoughtful and rational as we plan for 2025.

Despite this environment, Medicare Advantage enrollment is in an all-time high. And over 50% of individuals are still choosing MA. And that means there's still a clear value for what MA offers, and we're committed in the long term to having and operating a profitable and sustainable MA business.

It's a little early to talk about 2025 in terms of growth expectations. Our bids were recently submitted to CMS, and frankly, we are still getting feedback on that. In addition to that, the industry-wide submissions aren't known yet. We feel encouraged by commentary from peers that everybody is going to kind of price rationally and have benefit rationalization as we head into 2025. But we still have to wait and see what emerges once we have greater information from our competitors.

So at this point, there's a lot of unknowns. I will tell you, we maintained a very disciplined approach, offering competitive benefits while we are balancing growth and margins. I think we were very thoughtful in the plan designs that we put out there to make sure that we were focusing on profitable growth and the sustainability of this program for the long term. We are very focused on our D-SNP business, which is where we believe that we have a strong advantage when we think about our Medicaid and Medicare positioning. And we also did prioritization around our products in terms of our local market dynamics.

So it's still early to determine what growth is going to look like for 2025. We feel very good about how we've positioned our business on the heels of our strategy in 2024 to make sure that we have a sustainable long-term business in Medicare Advantage.

[Operator]

Next, we'll go to the line of Lisa Gill from JPMorgan.

[Lisa Gill, analyst]

I really wanted to just stick with Medicare Advantage for a minute. Can you talk about what you saw specifically in the quarter around trend? And then Felicia, maybe you can comment on what you included around trend assumption in your MA bids as we think about 2025.

[Gail Boudreaux, executive]

Great. I'll ask Mark to comment on your question.

[Mark Kaye, executive]

Thanks very much for the additional questions here on Medicaid. First, we are seeing a larger than typical pull-forward effect, and that's really driven by the increased numbers of Medicaid members who are losing coverage. You can think about this as beneficiaries who are facing imminent loss of coverage, in the month or so preceding that coverage loss, picking up additional benefits.

Second, member mischaracterization among the core expansion and specialized population has caused some localized revenue pressure as some members expect to regain coverage after previously being determined as ineligible.

And third on this topic of Medicaid, elevated outpatient trends in elective procedures.

Steve just flagged me, he said to talk about Medicare, so I apologize for that. On Medicare, the answer's very short, trends developed in line with expectations.

[Operator]

Next, we'll go to the line of Justin Lake from Wolfe Research.

[Justin Lake, analyst]

Appreciate the question. First, can you size the Medicaid trend increase that you're seeing here?

And then second, I just want to follow up on Kevin's question on government margins. Understand you don't want to give us specific absolute margin levels, but was wondering if you could share your expectation of the trajectory of margins in Medicare Advantage and Medicaid for 2025 versus 2024.

[Mark Kaye, executive]

Thanks very much for the question. Segment margins in the quarter improved by 20 basis points year-over-year. And I'd argue that the first half results here are consistent with our initial guidance range. And we expect full year margins to end within our initial outlook, up 25 to 50 basis points, primarily driven by the ongoing recovery of our commercial business.

From a seasonality perspective, there are two key comments I wanted to draw out here. For modeling purposes, second quarter revenue growth is going to mark the low point for the year, and we expect third and fourth quarter operating revenue and premium revenue growth rates to improve.

And then secondly, just on the MLR because it ties directly to your question. We now expect the third quarter MLR to be near the high end of our full year guidance range. And I note this specifically, Justin, as the current third quarter consensus estimate does not appear to capture the calendar day shift associated with the leap year, and that's going to have approximately a 70 basis point impact on the third quarter MLR.

[Operator]

Next, we'll go to the line of Erin Wright from Morgan Stanley.

[Erin Wilson Wright, analyst]

Can you talk a little bit about the investments you're making around CarelonRx and how you're thinking about the time line in terms of scaling specialty? And are there ample opportunities out there for you, like Kroger and Paragon, out there?

[Gail Boudreaux, executive]

Well, thanks, Erin, and welcome to our call. I think this is the first time you've been on our call, so it's great to hear from you. I'll ask Pete to comment.

[Peter Haytaian, executive]

Yes, no, thank you. We feel very good about our specialty strategy, and I appreciate the question. I'll try not to repeat what I said before and give you a little bit more context.

But as I noted, as it related to our specialty strategy, we acquired BioPlus last year in 2023. And again, we spent a lot of time last year in building out the infrastructure and the capacity to be able to assume Elevance scripts. And our focus as it relates to the near term is being able to migrate Elevance scripts, which will occur through this year and into 2025.

As you noted, we're going to be opportunistic, and we have been as it relates to things like Kroger, that provides additional scale for us. To give you a little bit of color on Kroger, it's about 500,000 incremental scripts. They also give us access to additional LDDs as well as having a presence in places like Puerto Rico, which could help us as well. And so we'll continue to be opportunistic as it relates to our specialty strategy and really on our focus to deliver whole health. We are anticipating, as I noted earlier, that Kroger would close Q3, Q4 of this year, and we're preparing for that and continuing to make investments around that.

And then I'd say as we move forward more broadly, and Gail touched upon this as it relates to our specialty strategy, there's a real focus on patient differentiation and whole health. We have a wonderful opportunity as we move forward to really drive whole health and capture all the value of Carelon, including things like integrating behavioral health and other services.

And so that's going to be our goals and focus moving forward. We feel very bullish about it. We feel very bullish about our growth. We feel very bullish about delivering on the Carelon strategy and whole health as we move forward.

[Operator]

Next, we'll go to the line Michael Hall from Baird.

[Michael Hall, analyst]

Just wanted to ask about your long-term growth target. In your deck, you now had a slight decline in Health Benefits long-term growth CAGR. And apologies if I missed this in your comments, but could you provide what -- some color on what's driving that? Is that MA, Medicaid, presumably not commercial?

And then I also think you reaffirmed long-term targets on Carelon. But over the past year since your Investor Day, CD&R partnership, BioPlus, the acquisition of Paragon, pending Kroger. The business seemingly has taken a very positive step forward in its evolution.

So would it be fair to say your prior target at Investor Day, most of those assumptions within your guide or long-term targets did not contemplate all these new developments? And specifically, Carelon Services revenue per consumer served, the 50% growth target by '27, now appears like there's much, much higher runway.

So just overall, taking a step back, even though you're reaffirming your target, is it true that now, today, there's significantly greater potential embedded earnings power within Carelon versus last year that can be unlocked for future years?

[Mark Kaye, executive]

This quarter, we are pleased to introduce our growth algorithm, which underpins our adjusted diluted earnings per share target of average annual growth of at least 12% over time.

You asked a little bit about the revision. And we have revised our enterprise revenue growth target from the high single to low double digits to high single-digit percent range, and that's primarily to reflect Medicaid-related attrition that has occurred to date and the impact of the prudent action that we're taking in our 2024 and 2025 Medicare Advantage bids in response to the risk model revisions.

Accordingly, our Health Benefits segment revenue CAGR should now be in the -- will now be in the mid- to upper single-digit percent range. But the key point here is our path is much the same. And that really means that we're expecting high single-digit to low double-digit percent growth in operating earnings.

And the key point here, to the second half of your question, with approximately 1/3 contribution from capital deployment, and that capital deployment can come through in the form of inorganic activity to support our Carelon businesses.

[Operator]

Next, we'll go to the line of Andrew Mok from Barclays.

[Andrew Mok, analyst]

Wanted to follow up on some of the Medicaid comments. It sounds like you're optimistic that rates get better in the back half, but also acknowledge a temporary disconnect that persists and expect higher Medicaid utilization in the back half. So if we translate that into MLR expectations, does guidance assume that Medicaid MLR peaks in 2Q and gets better from here with potentially better rates? Or do you expect it to peak at some point in the back half of the year?

[Mark Kaye, executive]

Great question. And the opening comments there are completely consistent with the way that we're thinking about it. You should really think about this as we now expect our full year benefit expense ratio to be in the upper half of that initial guidance range, i.e., 87% to 87.5%, principally because of the Medicaid dynamics that we're navigating. We're not looking to provide specific quarter-by-quarter guidance.

[Operator]

Next, we'll go to the line of Ryan Langston from Cowen.

[Ryan Langston, analyst]

Just a quick one for me. Prior year development was a bit more favorable than we expected. Can you maybe give us a sense on if that's just mostly from the fourth quarter? And if so, any kind of particular pockets of utilization you'd call out as maybe coming in better than expected?

[Mark Kaye, executive]

Thanks very much for the question. Let me put the prior year development in the context of the medical claims payment change this quarter because I think that's more instructive to understand the dynamics here.

And you saw medical claims payable in the quarter go down by approximately $1.3 billion versus the first quarter. And there are really several factors that drove this and then ultimately drove PYD development. And they include the reserve runoff due to Medicaid membership decline, the catch-up in claims paid associated with elevated reserves for industry-wide claim receipt delays in the first quarter, and then the improved operational environment that's reflected through our shorter cycle times.

And the key point here is that MCP, which is why it's more instructive, remained at historically high levels, both in aggregate and on a fully insured PMPM basis. And that indicates the continuity of our historical prudent reserving practices and our strong balance sheet.

[Gail Boudreaux, executive]

Thank you, Mark. And Ryan, welcome to our call for the first time. It's great to have you.

[Operator]

Next, we'll go to the line of Stephen Baxter from Wells Fargo.

[Stephen Baxter, analyst]

I just wanted to come back to the Medicaid utilization comments I think you were making in response to an earlier question. I'd love to expand a little bit on that. Could you comment perhaps on how much of the pressure is geographically isolated in some of your markets versus maybe more broad-based?

I think you were speaking to also some utilization of carrier from people that were expecting to lose coverage. Would you be expecting that dynamic to slow a little bit as redeterminations end? Or is that potentially offset by rejoiner dynamics or factors like that?

[Mark Kaye, executive]

Thanks for the question and appreciate the opportunity to provide additional clarification here. Certainly, we expect larger-than-typical pull-forward effect that we've seen in the second quarter to abate as the year goes on principally because we're through the tail end of redeterminations at this point. We are obviously working with the states to ensure that the timing and rate mismatch is appropriately adjusted.

On the member miscategorization. This is really ensuring that those members who are initially categorized, for example, as TANF are put in the more appropriate and cohort for purposes of rates, so think about ABD, for example. And then what we are really seeing elevate as the year goes on is the outpatient trends and elective procedures. And that's something that we fully accounted for in our MLR guide for the full year.

[Operator]

Next, we'll go to the line of Scott Fidel from Stephens.

[Scott Fidel, analyst]

Was hoping you could drill a bit more into the $4.3 billion of timing items that impacted operating cash flow. And then just wanted to see whether you expect all those to reverse in the back half of the year, and whether you're comfortable reaffirming your full year CFFO target of at least $8.1 billion. And if not, where you expect operating cash flow to land for the year.

[Mark Kaye, executive]

Appreciate the question this morning. Year-to-date operating cash flow is $2.4 billion. And to your point, that is a decrease of approximately $6 billion year-over-year. The key point here is that this includes $4.3 billion of timing-related items and approximately $1.3 billion of net cash outflows that are primarily associated with the runoff of our Medicaid reserves and the improvement in the operational environment which is reflected by shorter cycle times.

The timing-related item reflects a $3.6 billion impact from an additional month of premiums that we received from CMS in the year-ago period and so not a concern from our perspective.

On a full year basis, we do expect operating cash flow outlook to be slightly north of $7 billion, and that really reflects the year-to-date reductions in working capital. And specifically, as I mentioned a moment ago, that decrease in MCP driven by Medicaid membership attrition.

[Operator]

Next, we'll go to the line of Sarah James from Cantor Fitzgerald.

[Sarah James, analyst]

So in the prepared remarks, you guys mentioned a significant win with a Blue Cross Blue Shield partner. I was wondering if you could help us size your pipeline there and give us any clarity on how penetrated you are into that market. So how many of your Blues brethren do you currently have contracts with? And what's the opportunity look like to expand this?

[Gail Boudreaux, executive]

Great. Thanks, Sarah. Pete?

[Peter Haytaian, executive]

Yes, Sarah. Thanks a lot for the question. I appreciate it. And yes, we're really pleased with how services growth is going. We mentioned 26% growth in the quarter and a clear path of achieving our long-term objective. So we feel very good about that.

As it relates to your question, again, our focus is, as Gail said earlier, building capabilities internally and importing them externally. And we're seeing that play through. And you referenced the Blues. I would say that we are currently engaged with most of the Blues. And our strategy with regard to that is really landing and expanding, to be quite frank.

And this is a great example of that, where we had an existing relationship with the client. We continue to grow those services with that particular Blue. They see the value in that. We were able to convert some of those capabilities to risk. And I'll remind you that, that is a very big part of our strategy, assumption of risk, both on a category of service basis as well as a full risk basis. And so you'll see that continue to move forward.

As it relates to the pipeline. This year, we're doing very well. '24 growth year-over-year is very, very strong. So you'll see really nice improvement from that perspective. And as you would expect, we're already selling into 2025. A real focus in 2025 are on our behavioral health capabilities, our post-acute capabilities and then some of our Carelon Health businesses. So I appreciate the question, Sarah.

[Gail Boudreaux, executive]

Yes. Thanks, Pete, and thanks for the question, Sarah. As you heard from Pete, we have exciting opportunities to deepen our penetration because we do work with most of the other Blues today, and also other payers, quite frankly, and state partners has been a great opportunity for Carelon more broadly, and you're seeing that come through. So thanks for the question. We're excited about the opportunity there.

[Operator]

Next, we'll go to the line of George Hill from Deutsche Bank.

[George Hill, analyst]

I guess, Mark, I was just going to ask if you could bridge a little bit when we think about the 2027 OP margin targets in the MCO segments. Kind of like how you think about the sources of the margin expansion there. And I'd be interested, in particular, if you would talk about what your expectations are around the exchange subsidies and the growth of the exchange business.

[Mark Kaye, executive]

Thank you very much for the question, George, and certainly happy to talk through the algorithm at a little bit of a high level. So you can think about this as being driven by upper single-digit growth in revenue, enterprise operating margin expansion to 6.5% to 7%, and then the balanced approach to capital deployment, inclusive of share repurchases and strategic M&A.

On the revenue side, revenue growth is going to be driven by increased membership in the Health Benefits business, geographic expansion efforts and then prudent pricing to cover cost trend. And then similarly, in Carelon, key drivers are going to include the expansion of risk-based revenue in Carelon Services and the continued growth in CarelonRx membership.

On the margin side, expansion is going to reflect the disciplined operating expense management and the transformation of some of our business processes, leveraging new technologies, including AI. And that's coupled together with, or at least the way I think about it, effective medical management and underwriting discipline where they're going to enable us to achieve the enterprise operating margin target.

And then finally, consistent with our 2023 Investor Day guidance, we do expect to achieve approximately 1/3 of our adjusted diluted EPS growth rate through capital deployment.

[Gail Boudreaux, executive]

Thank you, Mark. And to your second part of the question around our exchange business. As you have heard us talk about, we have been, I think, very disciplined in our approach to expanding that business. We have had very strong results individually, up 35% year-over-year with the ACA growing almost 40%.

So as you think about that, our goal is to serve our members throughout their coverage transitions. We see a significant opportunity to continue that expansion, including geographic expansion, particularly for our members that were historically in Medicaid and now need other coverage. So again, a really nice opportunity, but you'll see that same sort of disciplined approach that we've shown throughout in the ACA.

[Operator]

Next, we'll go to the line of Whit Mayo from Leerink Partners.

[Benjamin Mayo, analyst]

Just quickly on midyear renewals. Just remind us how much of the commercial risk book renews in the second half of this year. And just how you're thinking about retention, membership, ability to take the required price action that you need.

And just as a clarification, is it fair that commercial is performing better than expectations on margin with government worse, at least in the first half? I just wanted to make sure I properly got this.

[Gail Boudreaux, executive]

Right. Thank you. I'm going to have Morgan Kendrick, who leads our Commercial business, address your questions, Whit.

[Morgan Kendrick, executive]

Yes. Thanks for the question. As we think about it, that cohort of business that we renew in July is about 25% of the risk-based large group business. And to camp on to that, it performed as expected. In fact, we're seeing persistency up a bit. We talked about attrition in the large group business with our January cohort on the first quarter call. That's abated, and we're seeing persistency improve and we're seeing the margins coming through. So we feel really good about how we're positioned for continued growth and expansion in that business moving forward.

[Operator]

Next, we'll go to the line of Dave Windley from Jefferies.

[David Windley, analyst]

I believe you have a cost savings plan targeting around $750 million that's maybe a relatively nearer-term initiative. I'm wondering if you could describe your progress since that. And then also, should we think about the benefits of those savings dropping through? Or are you mostly reinvesting those savings in some of your growth initiatives?

[Mark Kaye, executive]

Dave, thanks very much for the question. In terms of the 2023 business optimization activity, we are on track to realize the gross run rate expense efficiency improvement of approximately $750 million that we committed to do. And that's going to benefit both our operating performance this year, and it's going to help to establish the strong foundation for growth in 2025 and beyond.

If I step back just for a moment, and we covered this a bit in our prepared remarks, we do anticipate significant improvement in our operating expense ratio in the second half of the year as we continue to take additional steps to enhance operational efficiency. And we'll begin to see and realize those incremental run rate improvements over time.

[Gail Boudreaux, executive]

Thank you, Mark. And Dave, I might maybe just spend a moment because I think it's a great opportunity to share a little bit about how we're going about this. We first of all have been very disciplined about our expense management. More importantly, we believe the opportunity around generative AI for our business is expansive and it's going to materially impact all parts of our organization.

We've been focusing on a couple of things, and I know I've spoken about this before, enhancing experiences while driving cost down, but also fueling future expansion. And I would say, over the last few months, we've really accelerated those internal efforts. And again, this has been a journey, so it's not new, but we are going to start seeing the absolute impact of the AI technology and digitization around our significant operational areas.

And just a couple of things maybe to make this real as we transform. And there's kind of three areas around the engagement model that we think about: Members, providers and our own associates who are critical to this journey with us.

On the member side, we look at each interactions of our members, and we're using AI to make those much more unique and personalized and integrating it across our member touch points. Oftentimes, there's disconnects in those touch points, and that's a huge opportunity for us to take really personalized digital service and enrich that experience.

And what does that do? I mean the real impact you see it is improved access to care, better claims processing, less error rates, reduction of our calls, use of chat. So those are some very tangible ways that we're deploying that and have been over the last year. And you're going to start seeing that come through based on what Mark just shared.

The provider side is an area that I'm particularly excited about because we're looking at reimagining and streamlining all of our admin tests rather on an end-to-end basis with the provider life cycle. And that's a lot. But as you think about the impacts there, we touch not just providers, but also members. And some very specific things like automating the onboarding process, of how they come into our plans, refining roster management, specifically around data and how that drives downstream to claims. Also enhancing contract administration. And we think those interactions are going to improve our member experiences, but also improve our relationship and our ability to work in value-based care with our care providers and more seamlessly.

And then I'll end with associates because we know that they need to be part of this journey. It's also a cultural journey on AI that's going to drive, I think, greater efficiency. And we rolled out our Spark, which is our internal ChatGPT tool, to over 50,000 of our associates so that they can harness the capability, use it and improve their own productivity. And we're seeing really nice results from that.

So again, I wanted to just share that because I think our expense focus and efficiency is driven a lot by the impact we're going to see from that. And while we have a lot of opportunities, we're trying to look at the end-to-end impact of where we can take friction out of the system and fundamentally improve what we're doing.

So hopefully, that gives you a sense of how we're going about achieving the goals that we set, and we see huge opportunities going forward embedded into our growth algorithm for the future.

[Operator]

Next, we'll go to the line of Ann Hynes from Mizuho Securities.

[Ann Hynes, analyst]

I just want to focus on specialty. I know that Elevance is -- with your acquisitions, you're in-sourcing more specialty, not only on the dispensing side, but also the distribution side. So I'm just curious about your strategy longer term. Do you think there's more opportunity for specialty on the distribution side? And if you think there is, is there any therapeutic area you are focused on?

[Peter Haytaian, executive]

Thanks for the question, Ann. We think there's a tremendous opportunity as it relates to specialty. As I said earlier, our priority in the near term is of the Elevance scripts and absorbing the Elevance scripts effectively. And then also, as we talked about, what we're doing with Kroger. We continue to see opportunities to cover more LDDs.

And then in addition to that, as it relates to whole health, we are very focused on the patient experience. We are very focused on centers of excellence and how we can care for the members in a differentiated way by wrapping around additional assets.

Longer term, again, we will be opportunistic. But right now, we have a lot in front of us, and we want to execute against that effectively as it relates to specialty.

[Gail Boudreaux, executive]

Yes. Thanks, Pete. And Ann, I just want to highlight one point that Pete said, it's really an integration strategy. Specialty has a long runway for us. But the integration to our Carelon Services and what we do to deliver better value for our health plan members is really critical to our strategy. And I think that is unique. Our ability to take both the specialty pharmacy, but all the specialty services around these disease categories, we think is differentiating.

Last question, we're going to take now, please.

[Operator]

For our final question, we'll go to the line of Ben Hendrix from RBC Capital Markets.

[Benjamin Hendrix, analyst]

I just wanted a quick follow-up on Felicia's comments on MA bids for next year. I realize it's too early to talk about growth, but I think earlier in the year, you had talked about long term MA growth, focus towards Carelon markets. And I just wanted to see if you could provide any color on how your bids contemplate your geographic footprint evolving and also your density towards Carelon markets in 2025.

[Felicia Norwood, executive]

So Ben, thank you for the question. We've always been very strategic around where we want to see our MA growth as we go forward. As you recall, this past year, we've made very deliberate decisions around markets that we wanted to exit because we wanted to make sure that we positioned ourselves to long-term growth and performance.

When we think about our strategy today, it's certainly in those areas where we have Medicare and Medicaid business because the D-SNP business is incredibly important for us. And if you think about where things are going long term, having alignment around Medicare and Medicaid is critical for us. But ultimately, it's absolutely about being able to deliver for the Carelon flywheel as well.

The members that we are focused on, particularly in D-SNP and other SNP products, are very complex populations. And as we think about whole health, we've been working very collaboratively with Pete and the team to make sure that we are able to deliver a whole health for those that we are very privileged to serve.

So the footprint really is focused on density, certainly in our Blue markets, but being able to be focused on our Medicaid markets as well in places where we see opportunities to grow strategically with Carelon in the future, and that's the pathway and framework that we've established when we think about the long-term growth of our Medicare Advantage business, which we continue to be incredibly excited about as we think about being a lifetime trusted partner for those we serve. So thank you for the question.

[Gail Boudreaux, executive]

So thank you for your questions, everyone, and thank you for -- all of you for joining us today for your interest and your support. We look forward to sharing more about our progress that we're making on our enterprise strategy with you in the coming quarters and are confident that the balance and resilience of our diverse set of businesses positions us well.

Thank you for your interest in Elevance Health and have a great rest of your week.

[Operator]

Ladies and gentlemen, a recording of this conference will be available for replay after 11 a.m. today through August 17, 2024. You may access the replay system at any time by dialing [phone]. International participants can dial [phone].

This concludes our conference for today. Thank you for your participation and for using Verizon Conferencing. You may now disconnect.