Molina Healthcare Inc

NYSE:MOH

Earnings Call Transcript 2020-Q1

[Operator]

Good day, and welcome to the Molina Healthcare First Quarter 2020 Earnings Conference Call. All participants will be a listen-only mode. [Operator Instructions] Please note this event is being recorded.

I would now like to turn the conference over to Julie Trudell, Senior Vice President of Investor Relations. Please go ahead.

[Julie Trudell, SVP, IR]

Good morning and thank you for joining Molina Healthcare's First Quarter 2020 Earnings Call. With me today are Molina's President and CEO, Joe Zubretsky; and our CFO, Tom Tran. Press releases announcing our first quarter earnings and the definitive agreement to acquire Magellan Complete Care were distributed yesterday after the market closed. Press releases and the slide presentation regarding the MCC announcement are available on our Investor Relations website. A replay of this call will be available shortly after the conclusion of the call for 30 days. The numbers to access the replay are in our earnings release.

For those who listen to the rebroadcast of this presentation, we remind you that the remarks made herein are as of today Friday, May 1, 2020, 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 first quarter 2020 press release.

During our call, we will make forward-looking statements, including statements relating to our growth prospects, our 2020 guidance, a Magellan Complete Care acquisition and our long-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 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?

[Joe Zubretsky, President, CEO & Director]

Thank you, Julie, and good morning. This is an unprecedented time. The COVID-19 pandemic has had and will continue to have a profound impact on our country, our state partners, our members and our employees. Our team has worked tirelessly over the past two months to ensure that the needs of all of our constituencies are addressed quickly in this rapidly changing and challenging environment. COVID-19 impact on the U.S. healthcare system and the overall economy will continue to develop during the year, no doubt causing some short-term challenges, but also serving to highlight the important role government-sponsored healthcare plays in this type of crisis.

Clearly, the macroeconomic environment will significantly impact our results this year and for the foreseeable future. With that said, as a pure-play government managed care business, we remained well positioned at a time when reliable access to high-quality healthcare is more critical than ever to our members and our state partners. We would like to provide you with updates today on a number of fronts. First, we will cover the financial results for the first quarter. Second, we will discuss the new but hopefully temporary operating environment created by the COVID-19 pandemic.

Third, we will convey our guidance in the context of our first quarter results and this new operating environment; and fourth and lastly, we will provide some detail about our exciting acquisition of Magellan Complete Care that we announced last evening and other updates to our pivot to growth initiatives. Let me start with specific first quarter highlights. We reported earnings per diluted share for the first quarter of $2.92, with net income of $178 million and an after-tax margin of 3.9%, which slightly exceeded our expectations for the quarter. Premium revenue was $4.3 billion, an 8.9% increase over the prior year, which is consistent with our pivot to growth. The medical care ratio was 86.3%.

We experienced medical cost pressure in the Medicaid line of business early in the quarter, resulting from slightly higher-than-normal seasonal flu, combined with early, but at the time, unidentified COVID-19 costs. These increased costs were offset by lower medical costs in all lines of business very late in the quarter as elective and discretionary healthcare services began to be postponed and deferred. These offsetting factors, combined with negligible prior period reserve development, produced a medical care ratio that squarely met our expectations.

We managed to a G&A ratio of 7%, in line with our expectations, even after reflecting incremental expenses associated with the mobilization of our workforce to work at home, and other new operational protocols related to COVID-19. The total company after-tax margin was 3.9%, in line with our expectations, comprising product line margins, of 3.2% in Medicaid, 8.4% in Medicare and 4.1% in Marketplace. While a $2.92 earnings per share result modestly exceeded our expectations, its achievement is noteworthy in the context of the environment in which it was produced, which brings us to our second topic.

The dramatically different environment in which we currently operate and some of the changes we have made in response, to recap a few of these measures. As shelter in place directives and all-out shutdowns quickly spread throughout our geographic footprint, we swiftly moved substantially all of our associates to work at home. We accomplished this with no disruption to service, as service metrics have remained excellent. This is a remarkable accomplishment in light of the potential for disruption to utilization management, care management, network access and information technology infrastructure. Substantially, all of our company's workforce, 10,000 associates are currently working from home.

Many providers have seen disruption to their patient and revenue flows. Providers are struggling more than ever with utilization management, payment integrity routines and associated protocols in a rapidly evolving environment, which their cash flows have suddenly declined. While this requires adaptability on our end, we maintained strong performance in network management and utilization control. To assist providers in this challenging time, we accelerated claim payments by $150 million in late March and early April, while also extending the term of all non-COVID-19-related prior authorizations through September 1, 2020.

We also increased Telehealth visit reimbursement to be at parity with in person visits and have expedited credentialing to ensure we have ample provider capacity. We understand that COVID-19 creates a variety of challenges for our employees, including family members at home who may need support, children who require care. We quickly implemented broad-based programs to help them during this time, including two special stipends of $500 or a total of $1,000, and each of more than 9,000 of our employees. We also implemented pay enhancements for essential employees required to come to the workplace and an additional COVID-19 pay lead policy.

We are responding to dozens, if not hundreds, of special requests by our state customers, CMS and other governmental agencies. For example, we eliminated all member costs for COVID-19 testing and related treatments. We relaxed utilization management protocols in specific instances. We expanded Telemedicine access to all members and we made substantial contributions to the supply of personal protection equipment. We also committed support and resources for various nonprofit organizations serving those in need across the country. Support, supplies and monetary donations have been made to a variety of trusted organizations that directly serve vulnerable populations.

In summary, we would characterize our first quarter results as more than respectable, in the context of unprecedented disruption to the entire spectrum of traditional managed care operations that occurred over the span of just a few weeks. In this difficult operating environment, it should be noted that our financial position is strong as we had already done the hard work to develop very solid capital and liquidity positions. A few words about these matters. Our share repurchase program is now completed as we purchased a total of 3.4 million shares in the quarter for approximately $450 million at attractive prices.

We drew down $380 million and remaining capacity of our term loan facility to bolster our liquidity. We availed ourselves of this inexpensive debt instrument, which would have otherwise expired in the coming quarter. And after the completion of the share repurchase program and the term loan facility draw, we are holding approximately $840 million in excess parent company cash. I'll turn now to our third topic, a discussion of our near-term outlook, starting with a description of the current dynamics of our industry.

The business model, government managed care, particularly Medicaid, has been stress tested through extreme economic scenarios, including the financial crisis, the subsequent boom and now the effects of the world's worst pandemic in over 100 years. The model has proven to work in both robust economies and in deep recessions. In strong economic environments with low unemployment, there are relatively fewer Medicaid and subsidized Marketplace members, capitation rates tend to be on the strong side of actuarial soundness as state budgets are well funded. During challenging economic environments with high unemployment, there are relatively more Medicaid and subsidized Marketplace members, capitation rates tend to be on the lighter side of actuarial soundness as state's budgets become tighter.

So while government managed care, particularly Medicaid, is certainly impacted by this environment, the business and financial model flexes to accommodate these unusual and sometimes extreme circumstances. In an extreme environment, like the one we are in today, government intervention is often required to provide rescue packages, backstop the healthcare system and the disadvantaged population. The current crisis is no exception, as Congress and The White House have stepped forward with a number of measures.

The Families First Coronavirus Response Act includes additional assistance for state Medicaid programs in the form of an increase to the FMAP match. Each state has received a 6.2% increase, which will extend throughout the COVID-19 public health emergency declared by the Secretary of Health and Human Services. There have also been a number of legislative aid packages enacted, including the $2 trillion stimulus package and the additional $484 billion supplemental COVID-19 spending package referred to as Phase 3.5. These funds in various forms, have been made available to providers, small businesses, individuals and a number of other constituents which should ease the pressure on the healthcare system during this crisis, which indirectly should help the viability of Medicaid programs.

In short, we have a stress-tested business model and significant government intervention designed to accelerate the economic recovery. But even in the presence of these very positive factors, which support a favorable outlook for the longer-term trajectory of the business, the near-term quarter-to-quarter outlook remains difficult to predict. This brings us to a discussion of our guidance for the remainder of 2020. Two overarching factors must be considered in providing guidance in this environment. First, we face a remarkably wide range of possible medical cost scenarios that could emerge over the next nine months.

We have modeled many utilization scenarios for the balance of the year, all of which are plausible, but each of which produces dramatically different results. Second, we must consider the likelihood of a significant increase in membership as a direct result of widespread unemployment. With rising unemployment levels and the suspension of Medicaid eligibility redetermination in many states, we are now likely to experience a significant increase in combined Medicaid and Marketplace enrollment. But by how much? We do not yet know. These COVID-19 effects on medical cost and membership are widely expected to have a net positive effect on near-term earnings.

However, we are not yet prepared to draw this conclusion based on the many variables and uncertainties that remain as managed care moves through the full course of the pandemic. We are, however, prepared to state that we view our original 2020 plan in our previously announced guidance with enhanced confidence. Accordingly, we are reaffirming our full year earnings per diluted share guidance range of $11.20 to $11.70. Let me briefly walk through the thought process that supports our guidance.

With respect to medical costs, at this point, we cannot predict with any degree of precision how the COVID-19 situation will impact medical costs in 2020 for a variety of reasons. First, the level of future-direct COVID-19-related costs is not yet estimable, as the incidence rate of diagnosis and hospital admission and the related cost per episode remain unclear. We observed a steep decline in elective medical procedures very late in the first quarter, through the month of April, but we do not know how long this phenomenon will persist and begin to normalize. The prevailing expectation is that discretionary utilization could be very low for the second quarter and perhaps beyond, but then rebound quickly in the second half as COVID-19 abates, and health system capacity frees up.

And any potential short-term and nonrecurring benefit from lower utilization is partially limited by rebates we could be obligated to pay under applicable minimum MLR regulations. With respect to our administrative costs, our operating efficiencies are secure, and our operating leverage discipline is intact. There will continue to be G&A pressure, however, related to nonstandard operating protocols and the cost structure required to service any significant additional membership. Investment income will certainly be lower than our original forecast as money market and other maturing fixed income investments grow over into much lower-yielding instruments.

We call two, that our portfolio is short dated, so the impact is rather immediate. Before the onset of COVID-19, we fully expected to achieve our membership guidance. With the unfolding unemployment levels and suspension of Medicaid eligibility redetermination, we are now likely to exceed that guidance. But by how much? We do not yet know. We have developed various models and scenarios based on macro and microeconomic factors, which produce widely different results. The eventual outcome will be influenced by several key factors, including unemployment levels, particularly in the lower wage services economy, availability of spousal coverage and COBRA uptake.

The impact of these factors is likely to be greater in the economically sensitive Medicaid expansion sector. Relatedly, pre-COVID, we fully expected to achieve our premium revenue forecast for the year of $17.4 billion. Our previous membership forecast was achievable, and our rates were generally known. Now it seems likely we could exceed our revenue forecast, depending on the timing and extent of the additional membership we just discussed. The YourCare acquisition will be an additional source of growth when closed. I also note again that any potential upside to annual earnings if limited by rebates, we would be obligated to pay under applicable minimum MLR regulations.

In addition to our compliance with such regulations, even if our MCRs come in lower than our own internal targets, with a mindfulness of our civic responsibilities, in order to address any unexpected imbalances, we could choose to reinvest some of that margin and provider based quality of care initiatives and additional benefits for our members, here in the communities where they live. While the current near-term economic environment is unpredictable, government managed care business has consistently shown very attractive growth characteristics with compelling free cash flow generation.

We are in the right business at the right time to serve our members, support our state partners and move with confidence and conviction into the future. However, we also believe that making accurate and perhaps bold statements about our longer-term future makes little sense at this time. Accordingly, we have decided to postpone our May 28 Investor Day and perhaps later in the year. For now, we are strictly heads down doing the hard work we need to be doing. I turn now to the fourth and final area of commentary this morning, an update on the many activities relating to our pivot-to-growth strategy.

Even with the extraordinary level of activity related to COVID-19, which is now our highest priority, we have not lost sight of our near-term focus on top line growth. Opportunities to enhance and expand our portfolio in a substantial and synergistic way occur infrequently. Last night, we announced just such an achievement as we signed a definitive agreement to acquire Magellan Complete Care, or MCC, from Magellan Health. This transaction caps nearly a year-long effort, long predating the COVID-19 crisis and delivers compelling benefits that will endure for years to come. A single bolt-on acquisition, we add businesses in three new states and three over lapsed states to our portfolio at a purchase price equal to approximately 30% of the target's revenue. Pro forma, newly expanded Molina Healthcare which surpassed the $20 billion mark in annual revenue.

Let me briefly describe the businesses we purchased, their strategic fit with our portfolio and the resulting financial metrics. As of December 31, 2019, MCC served approximately, 155,000 members across six states, Virginia, Arizona, Massachusetts, New York, Florida and Wisconsin. Full year 2019 revenue was greater than $2.7 billion, and we project it to grow to $3 billion within two years.

Magellan Complete Care comprises the following businesses: Full-service Medicaid in Virginia, a new state, full-service Medicaid in Arizona, also a new state, dual eligibles and Massachusetts branded senior whole health, again, a new state, managed long-term care and New York Metro area, branded senior whole health, a new geography, and two small businesses, one in Florida and one in Wisconsin.

The addition of the MCC properties allows us to apply our previously demonstrated operating excellence to bring these businesses to our target margins, harvest the full benefit of fixed cost leverage by adding more revenue with little additional fixed costs and launch Medicare and Marketplace in new Medicaid geographies. Turning to the financial metrics. The $820 million transaction, net of certain tax benefits, is expected to close in the first quarter of 2021.

The purchase is funded entirely with cash on hand. We projected it will deliver returns well in excess of our cost of capital as our demonstrated operating capabilities puts us in a unique position to improve the margins of these businesses. As we move margins to our targets, deploy our enterprisewide platforms have the benefit of fixed cost leverage, we expect the acquisition to be accretive by approximately $0.50 to $0.75, cash earnings per diluted share in the first year of ownership and accreted by at least $1.75 in cash earnings per diluted share in the second year of ownership.

These new additions to our portfolio demonstrate how carefully target M&A can accelerate our pivot to growth. With the addition of MCC, we will serve more than 3.6 million members in government-sponsored healthcare programs in 18 states. We will achieve enhanced geographic diversity, greater portfolio of depth, a meaningful addition of durable top line revenue. We will also be able to maintain continuity of care for MCC's members and stability for its state partners. These qualitative considerations have an added importance in the current environment and demonstrate our unwavering commitment to capably assist our government partners and bringing high-quality healthcare to individuals and families during this time of great need and into the future. Let me provide you with some additional highlights as it relates to our pivot-to-growth strategy.

First, we terminated our agreement to purchase next level health due to the seller's stated unwillingness to close pursuant to the terms of the acquisition agreement. Second, in New Mexico, all legislative and political hurdles have been passed in connection with development of the first ever Indian managed care entity. We have been named as the exclusive manager of the managed care entity with the Navajo Nation. We stand poised and ready to serve the 75,000 Navajos eligible for Medicaid. Third, as previously announced, Texas canceled all of the new contracts associated with the STAR+ reprocurement awards, canceled the STAR chip RFP.

The state has commented that it is not likely to reprocure this contract in the near term. And thus, we expect that our revenue base on this contract is secure at least through 2021. Fourth, we await the decision by the state of Kentucky on its Medicaid RFP, which we expect to be issued before the end of the second quarter. While Tennessee is the only state to specifically announce that it is postponing its RFP due to COVID-19, we believe there will be a general tendency by other states to also delay procurements until the COVID-19 crisis has abated.

And finally, in our continued efforts to shape our business portfolio to optimize value, we have decided to sell our Puerto Rico Medicaid business. In doing so, we will work closely with the regulatory authorities and the provider community to ensure that our members in Puerto Rico are not disrupted and have reliable continuity of care. Now some concluding remarks. I hope it is clear to all that during this time, our members and customers are going to make requests of us to do the extraordinary. Our philosophy is to provide the health first and ask questions later. We trust that we will be adequately rewarded for the work we do and the services we provide.

Although in this environment, we expect some nontraditional protocols to be invoked. This philosophy is not incongruent with shareholder friendliness at all. In fact, it is the epitome of a prudent environmental, social and governance philosophy, and the pillar of long-term business sustainability. We will fulfill our moral, civic and patriated duty, and we will emerge from this an even stronger company. Not only are we proving to be flexible and adaptable in this changing environment, but we will make sure our performance during this challenge, enhances our growing reputation among our existing customers and potential new customers alike, as a go-to resource in government-sponsored managed care.

Before I turn the call over to Tom, I want to recognize our management team and the entire Molina community. During this unprecedented time, our team, 10,000 strong, has worked tirelessly to ensure that the needs of all of our constituencies continue to be addressed quickly and effectively. The true highlight of the quarter was the performance of our entire workforce and their rapid operational and clinical response across every dimension of the healthcare ecosystem, truly inspirational. They never lost sight of the members and the state partners who are counting on us to deliver whatever the challenge.

Now I will turn the call over to Tom Tran for more detail on the financials. Tom?

[Tom Tran, CFO & Treasurer]

Thank you, Joe. This morning, I am going to provide some details on our first quarter results, provide additional insight into COVID-19's impact on our medical costs, and then I will provide more color on our 2020 guidance. So let me start with the quarter. Premium revenue for the first quarter of 2020 increased 8.9% to $4.3 billion compared to the first quarter of 2019, primarily due to rate increase in our Medicaid and Medicare lines of business.

The consolidated MCR for the first quarter of 2020 increased to 86.3% compared to 85.3% for the first quarter of 2019. While prior year's reserve development in the first quarter of 2020 was negligible, the MCR in the first quarter of 2019 was positively impacted by approximately 140 basis points of favorable reserve development. The increase in the MCR in the first quarter of 2020 also reflects the increase in marketplace MCR.

Now for some details on our results by line of business. In the Medicaid business, the MCR in the quarter was 88.9% compared to 88.5% in the first quarter of 2019. Our Medicaid performance for the first quarter of 2020 was solid. As we continue to manage medical costs, harvest the benefits of our payment integrity and utilization management protocols and attained risk score commensurate with the profiles of our members.

In addition, the MCR in the prior year quarter was positively impact by the aforementioned favorable reserve development. The impact of COVID-19 on medical costs in the first quarter of 2020 was not significant. We experienced medical cost pressure in the Medicaid line of business early in the quarter, resulting from slightly higher-than-normal seasonal flu combined with early but lastly undetected COVID-19 costs, diagnosed as severe respiratory illness and pneumonia. We also experienced increased pharmacy costs in the quarters as members refuel the chronic medications in advance of the height of the crisis.

This increased costs were offset by lower medical care costs in all lines of business very late in the quarter, as elective and discretionary healthcare services began to be postponed and deferred. In the Medicare business, the MCR for the first quarter of 2020 was 81.7% compared to 84.7%, in the first quarter of 2019, due to rate increase and higher quality incentive revenues. Finally, in the Marketplace business, the MCR for the first quarter of 2020 was 72.3% compared to 52.2% for the first quarter of 2019, which was mainly attributable to our lowering price in 2020 in an effort to be more competitive.

The G&A ratio for the first quarter of 2020 improved to 7% compared to 7.3% in the first quarter of 2019, primarily related to increased revenues and positive operating leverage. The G&A for the quarter reflects approximately $6 million of incremental expense associated with the mobilization of our employees to work at home, along with other operational protocols associated with COVID-19.

Now on to COVID. Let me offer some additional insights, but recognize that this picture is unfolding in real time. Some statistics, as we sit here today. Through April 27, we had a total of 950 members hospitalized with COVID-19, based on early data, the average length of stay is approximately 10 days, and there is no statistically credible cost per episode yet. In terms of geography, the health lands most impacted by COVID-19 are Washington, California and Michigan.

While Washington was the first state impacted, Michigan has experienced the highest number of cases. While many of our states are estimated to have peaked, some have not. In proportion to our membership by line of business, Medicare has the highest percentage of incidents, followed by Medicaid and then Marketplace. Lastly, we experienced a steep decline in elective medical procedures beginning very late in March, which has continued through the month of April. Turning now to our balance sheet and cash flow. Our reserve approach remains consistent with prior quarters, and our reserve position remains strong.

Days in claim payable represents 49 days of medical cost expense compared to 50 days in the fourth quarter of 2019. Operating cash flow for the first quarter of 2020 was $136 million, with the change from the first quarter of 2019, primarily due to the timing of government payments and accelerated payments to providers. As of March 31, 2020, our health plans had total statutory capital and surplus of approximately $2 billion, which equates to approximately 347% of risk-based capital.

Turning now to our 2020 guidance. We have reaffirmed our full year 2020 earnings guidance range of $11.20 to $11.70 per diluted share. First, let me walk through what is included in our full year guidance. Net investment income will experience headwinds in due to lower yields. We factor this in our guidance, and we expect it to be approximately $0.27 per share of headwind for the full year. Incremental G&A expenses related to COVID-19 for the balance of 2020 have also been considered.

Now let me walk through what is excluded from our full year guidance. We recognize that rising unemployment levels are likely to result in an increase in Medicaid and Marketplace enrollment. However, we do not know the magnitude or timing and therefore, membership increase related to COVID-19 are excluded from our full year 2020 guidance.

Due to uncertainty of COVID-19's impact on utilization and medical costs, its impact on net medical costs is excluded from full year 2020 guidance. I will also note that our full year 2020 guidance does not include the impact from previously announced acquisitions that have not yet closed. While the timing, duration and severity of COVID-19's impact on our financial metrics and earnings on an intra-quarter basis and throughout the rest of the year is not entirely predictable, we believe this is the most reasonable approach to providing guidance for the full year of 2020.

This concludes our prepared remarks. Operator, we are now ready to take questions.

[Operator]

[Operator Instructions] The first question today comes from Justin Lake of Wolfe Research. Please go ahead.

[Justin Lake, Wolfe Research]

Thanks, good morning, Joe, can you talk a little bit about the Magellan acquisition in terms of where you see margins along the trajectory of the of the accretion analysis? So where do you expect margins to be at the end of year one and year two to get to that accretion number?

[Joe Zubretsky, President, CEO & Director]

Sure, Justin. Let me I'll make sure I frame the deal first. This is right out of our playbook. And the way we think about this is this is sort of six bolt-on and tuck-in acquisitions all bundled into one. And as you know, what we've said many times, is we look for acquisitions that have stable membership, stable revenue flows and if they're underperforming, we certainly will bring to bear our operational excellence discipline and rigor in order to improve margins. So the way we look at this is you've seen the numbers. They are slightly profitable in the aggregate, approximately a 1% EBITDA margin. As you know, we've averaged about 6% or 6.5% EBITDA margins in the last couple of years.

And if you can then pack on positive operating leverage, because we're not going to increase the fixed cost base of running our enterprise when we take these on, you can easily see how we got to the $0.50 to $0.75 of accretion in the first full year of ownership and at least $1.75 of cash earnings per share accretion in the second full year of ownership. So in the first year of ownership, we will most likely operate on their cost structure as integration activities take place. In year two, we will be migrating to the Molina cost structure, both our G&A platforms and the impact of payment integrity, utilization, management and risk or quality will begin to improve the medical cost ratios. And sometime in year three, we should reach the margins that we enjoy today in the moving of portfolio. Does that help?

[Justin Lake, Wolfe Research]

Yes. That's really helpful, Joe. And then if I could just ask one more on cash. You talked about, I think, $840 million coming out of the quarter. Can you walk us through the moving parts for the rest of the year in terms of dividends from the subs, etc? And where you expect to end the year from a cash perspective as well as a leverage perspective?

[Joe Zubretsky, President, CEO & Director]

Sure, Justin. Well, yes, we ended the quarter with $840 million of free and clear cash at the parent company. If we achieve our earnings guidance for the year, we can project we project to extract approximately $500 million of ordinary dividends from our operating subs. That could be higher if we're able to get extraordinary dividends. Bear in mind, we have a $500 million untapped revolver. And in connection with this transaction, we topped up that revolver with a short-term facility of an additional $400 million.

So to recap, $840 million of cash, our projection of extracting at least $500 million of ordinary dividends during the balance of 2020 and then two untapped facilities which aggregate to $900 million of debt capacity. I'll also remind the group that our high-yield debt is trading really well right now. And that we believe we have really good access to the high-yield market if we wanted to make any of this financing permanent. So that's the cash flow story.

[Operator]

The next question comes from Scott Fidel of Stephens. Please go ahead.

[Scott Fidel, Stephens]

Hi, thanks. Good morning, everyone. First question, just wanted to ask on MCC and clearly, significant margin improvement opportunity. I think that is embedded in that deal for you. Interested what you're thinking in terms of what you can do to also accelerate top line growth from the MCC assets as well. And specifically, maybe thinking about the three new states, that you'll be entering. How could this potentially sort of tap into additional business-line opportunities for you and then in some of the other tap-on products that you'll be adding from this?

[Joe Zubretsky, President, CEO & Director]

Sure, Scott. There actually is an embedded growth rate in the acquired portfolio itself. The Arizona full-service Medicaid contract is at its very early stages. If I remember correctly, about 13,000 members at the end of the year with approximately $80 million in revenue. That's projected to achieve a membership of 75,000 to 80,000 over the next year. Because it enjoys a preferred position in the auto assignment algorithm in the state. So there's an inherent growth rate due to the Arizona property. And the point the second point you make is spot on. As you know, our strategy is to take our full product line and penetrate it into our Medicaid footprint.

And now that we have a new Medicaid footprint in Arizona and in Virginia, we absolutely plan to launch a DSNP product in our Marketplace product in those geographies. And then, of course, just being in the boroughs in Westchester in New York city, gives you plenty of opportunities to look for bolt-on other bolt-on opportunities in the city and to perhaps grow the business. As you know, right now, we're in upstate New York. And don't have a produce in downstate New York. But this gives us plenty of opportunity to think more broadly about how to participate in Metro New York.

[Scott Fidel, Stephens]

Got it. And then just my follow-up question. I understand that you're just hesitant right now to build in anything on revs or enrollment from rising unemployment. Just interested if you can maybe just give us a little insight into maybe just what you've seen so far in April. Possibly in the Medicaid and the Marketplace exchange lines, especially given states relaxing redetermination reviews?

[Joe Zubretsky, President, CEO & Director]

Sure. I'm going to break with tradition air a little bit. You tend not to talk about what's going on in the current quarter, but this is an unusual time. And the points you mentioned are really, really important to pretend what could happen to membership. First thing I would point to is before talking about April, for the first time in many, many quarters, maybe even since I got here, we actually had membership growth in Medicaid sequentially March 31 over the end of the year.

Good growth in Washington, Michigan, held steady, good growth in Illinois, offset by some losses in Puerto Rico. So our efforts to work with providers to keep more members in the system and to bring on more members are pushed to make sure that in the redetermination and re-eligibility process that we hold on to more members is starting to work. Pushing that forward now to the direct question you asked, it's even looking better in April.

Our Medicaid membership is likely to be up over 30,000 members just in the month of April. And the interesting point I will make is we believe we're pretty sure that none of that membership arrived as a result of accelerated in the surge in unemployment. It's too soon to see people that became unemployed in March, end up in managed Medicaid. So we believe that the 30,000 growth in April is truly due to the suspension of eligibility of determination in the states.

And without that churn, you're just not going to lose the members. They stay longer, they stick longer. And as you know, many states actually have suspended redetermination, and some have even announced perhaps even for a full year. So that really sort of pretends well for the membership growth before the surge due to unemployment actually arrived, which is likely to in May and beyond. Does that help?

[Operator]

The next question today comes from Kevin Fishbeck of Bank of America. Please go ahead.

[Kevin Fishbeck, Bank of America]

Thanks. I was just wondering what you think the MLR might be on these new members coming into the Medicaid and to the exchange programs. I guess last recession, we did see some heads up demand initially on the new medicated lives. And just thinking about whether you expect that to happen. And on the Medicaid side, if these patients are members or people who would have been on COBRA, you expect any adverse MLR there?

[Joe Zubretsky, President, CEO & Director]

Yes, we have various views on it. I mean I think basically, and I think it's generally you say that if somebody needs insurance, they buy it. And if they don't, they won't. So there's just sort of an inherent bias, adverse selection bias in the whole process. We actually have various scenarios, some of which might say that there's higher acuity coming in through membership and some say that it will be on par with what we have. It's hard to say and where the number is coming from.

Are they coming from a very rich self-insured plan and a big company? Or are they coming from a small group plan for a small business? So it's really hard to say right now, which is obviously one of the reasons why we're reluctant to predict what this surgeon membership brings. We'll see a surge on membership. We have to build the operational platforms and hire the people to service that membership and then as you suggested, the acuity of that membership is unknown. But I think the prevailing wisdom is, while it might be slightly better and worse than the average, that's not going to be a significant factor in taking on these members.

[Kevin Fishbeck, Bank of America]

All right. Great. And then when I look at your guidance, you're excluding a number of things from your guidance, but I see that pretty much all of them are the things that are most be positive than they are to be negative. Is there anything negative, really, I guess, that is not included in guidance or has the potential to be a significant negative?

[Joe Zubretsky, President, CEO & Director]

If understand your question correctly. The two factors that we updated in our guidance are one that's sort of easy to understand and engage. And that is our portfolio is going to roll over into lower-yielding investments. It's irrefutable and already happening. And I think Tom pitched that as a $27 earnings per share $0.27 earnings per share headwind in our guidance. We also believe putting the accelerated membership aside that we will incur higher SG&A related to COVID operational protocols, financial assistance to our employees, etc, which also we factored into our the reaffirmation of our guidance, but we did not update for anything else.

[Kevin Fishbeck, Bank of America]

Yes, that's what I'm saying. I'm saying you reaffirmed guidance, we're including some negative thing. You're actually getting a lot of the members, executing the deals and these things all seem like they're actually going to be upside to the number. So though it seems like there's going to be some upside to the number. I just want to know if there's anything else that you're excluding that you think might be the opposite way of the counteract or it's really just conservatism?

[Joe Zubretsky, President, CEO & Director]

No. It's basically just saying the production of core earnings just got a little better, but we did not factor in any of those COVID-19 impacts. But yes, with those headwinds, we're saying core earnings gets a little stronger.

[Kevin Fishbeck, Bank of America]

It's great, thanks.

[Operator]

The next question today comes from Gary Taylor of JP Morgan. Please go ahead.

[Gary Taylor, JP Morgan]

Hi, good morning. I had two quick questions. The first one, I just want to go back to, Joe, your comments about Medicaid MLRs? I know there's also some states with pre-tax caps, but sort of the curves on how low MLR could effectively go and flow through earnings. So certainly, we understand that those exist. I guess the question is, on a state basis, are those all typically just calculate on the state fiscal or calendar year. There's no rolling period like there are in some of the federal minimum MLR requirements.

[Joe Zubretsky, President, CEO & Director]

Yes, Gary, that's my understanding. And there's very few adjustments like in the Marketplace MLR where taxes and all these other factors create a dramatic difference between the regulatory minimum and what you publish in your financials. But yes, seven of our 14 states have some form of MLR floor, ranging from 85% to 86%, except Puerto Rico, which is 92%. Those also exist in the expansion population and exist in the ABD business, but usually at different rates. So yes, there are very few adjustments from what you publish, and the minimum. And by understanding is they work on a one year fiscal year basis, not a rolling basis.

[Gary Taylor, JP Morgan]

And my second question is you talked about 950 members hospitalized with COVID-19, no statistically credible cost per case. So I guess two questions. One, are those are the provider revenue cycle claim submissions being materially delayed? And then secondly, I thought most of your contracts in Medicaid would pay on a DRG basis, are you saying you're just not seeing the DRG coding yet? Or is there enough complexity to sort of outlier payments on outlier length of stay cases that dedicating all that still doesn't give you a good sense of the numbers yet?

[Joe Zubretsky, President, CEO & Director]

No, it's actually not that complicated. Again, 1,000 cases, so you can't draw any statistical credibility to that. We have five day stays, and we have one month stays. We have people in the ICU on ventilators and people that go in and go out. Cost range from $10,000 per episode to $100,000 per episode. But we're now capturing all the codes.

And I think while Tom was suggesting in his prepared remarks was early in the quarter we are getting tagged with all types of respiratory elements, particularly in Washington and California. This was before COVID was a phenomenon. And we've hindsight and better information now, we have attributed that, and it has been attributed to COVID-19 actually showing up in Washington and California far before anybody actually thought it was.

But no, there's no intrigue around how we're getting billed and coded for these things with only 1,000 data points, as I said, it's hard to draw any statistical conclusions. On your other point, we are not seeing any dramatic change in the administrative aspects of our provider dealings. We are seeing a drop in pre-authorizations, and claim submissions just because of the elected procedure deferrals. But there has not been a huge disruption in either the level of payments and the level of submissions that we've observed to date, that could change here over the next couple of months.

[Gary Taylor, JP Morgan]

Thank you.

[Operator]

Next question comes from Matthew Borsch of BMO Capital Markets. Please go ahead.

[Matthew Borsch, BMO Capital Markets]

Yes, sir. Thank you. I was hoping you might comment on how you're thinking about the changes in enrollment trajectory over time. I realize that probably a number of scenarios you're looking at for how this recession plays out. But for lack of a better metric, I mean, do you think comparing with sort of duration and gap for 2008, 2009, it's the broad side of the barn?

[Joe Zubretsky, President, CEO & Director]

Sure. Well, Matt, all of you have seen all of the different pundits and think tanks project what this might look like with unemployment scenarios ranging from 10%, 20%, even up to 30% with Medicaid roles expanding anywhere from 10 million to 30 million members. A very wide range of results. I think as we said in our prepared remarks, there are lots of factors to consider here. Number one, COBRA used to be a rather significant factor in how many members would come in.

But now with subsidized Marketplace, you could argue that there will be more members attracted to the subsidized Marketplace which might be the 102% of premium that COBRA charges. So there's all types of phenomenon. Even on the unemployment rate, we have to look at subsectors of the economy. We're looking at the lower wage service economy. And I believe that's not going to come back quickly. That sandwich shop, that drycleaner shop, that coffee shop, these small businesses are going to struggle to get back into business.

And we think that the lower-wages service economy will remain have higher unemployment rates for a longer period of time than perhaps the higher-wage sector of the economy. So if you take our market share, if you do a projection of unemployment in all of our states, ranging from 10% to 20%, look at our market shares, in Washington, it's 50%. In most states, it ranges from 5% to 25%, 9% on average. You can actually craft a scenario where the membership peaks at a pretty significant number. As unemployment softens, some of that goes back. But I think there's a permanent delta here on that lower-end service economy that's going to struggle to get back into business quickly.

[Matthew Borsch, BMO Capital Markets]

Yes, that brings up a very closely related question, which is, again, we're shooting the dark here. But would you predict we might see some structural changes in how healthcare coverage is handled at the small group and particularly the lower end of the small group, maybe lower wage end of the spectrum, given it's been volatile for a while, and now it's even more volatile.

[Joe Zubretsky, President, CEO & Director]

It's a good question. I say during the all the swirl and the activity around this, I hadn't given that much thought. But the way we look at it is we now do have a product suite that works all the way up to 400% of federal poverty level when you think about it. So when we have Medicaid expansion in a variety of states, up to 138 then we have a highly subsidized Marketplace up into the 200, 250 range. We have products that the population can buy all the way up to that level. And so it would seem that we have the product suite, both commercial and government-sponsored that we need to satisfy the population. I hadn't given your specific question, a lot of thought during all this, but I will do so and get back to you on that.

[Matthew Borsch, BMO Capital Markets]

Thank you.

[Joe Zubretsky, President, CEO & Director]

You're welcome.

[Operator]

The next question comes from Josh Raskin of Nephron Research. Please go ahead.

[Josh Raskin, Nephron Research]

You're asking. Your line is live. Perhaps, your line is muted. Sorry about that. Sorry I was on mute question around the exchanges. And I know it's early, but sort of April application processes and things that are coming in. I'm just trying to get a sense of as individuals move from the commercial markets into whether it's Medicaid or Marketplace. Sort of where do you think the magnitude of impact is going to be? And again, is there any data that you're seeing on Marketplace applications to date, that would be helpful.

[Joe Zubretsky, President, CEO & Director]

Right. We are seeing, I'd say, at this early stage, given that April data I was speaking about, we haven't seen Marketplace growth yet. But we have seen a slowing in the natural attrition rate. As we said at the beginning of the year when we gave our Marketplace forecast, we have reduced our attrition rate outlook to 1%, 1.5% a month. Which would suggest 3,000 to 4,500 members, that is slowing. We believe membership will start growing again here very soon. The point I was making before, I think, is the important one.

Is that COBRA charges 102% of the full premium? And we believe, based on all the models we've looked at, that a highly or even reasonably sized subsidy in the Marketplace products, silver product, let's say, beats 102% of commercial all the time. And so we're likely to see more uptake in the Marketplace than maybe in past recessions when the Marketplace actually didn't exist. So now that it does exist, I think it's going to be the net beneficiary of folks who come out of commercial plans. And find that highly subsidized Marketplace product beat staying on COBRA.

[Josh Raskin, Nephron Research]

And Joe, just to follow-up on that point. Is it fair to assume that I know you talked about some of the adverse selection bias in processes like this where people buy insurance if they need it. But in this situation, isn't it fair to assume that COBRA, those remaining on COBRA are going to be ones that are more focused on continuity of care and have chronic needs and things like that? Are you assuming that the Marketplace membership may actually have a positive bias?

[Joe Zubretsky, President, CEO & Director]

Well, I think that's an excellent point. Generally speaking, if you're in the middle of some kind of expensive treatment protocol or our chronic member on expensive drugs, you just don't move because you're happy with what you have. But as you know, COBRA has unlimited life, and those members have to go somewhere eventually. Right now, we're not assuming anything other than we're building the infrastructure to make sure we can handle the influx of members. Jason Dees, who runs our Marketplace business, is very mindful of how do we capture really risk scores and risk profile in these members. So we know when we get them, how to treat them, how to get them into care plans, etc. So very early stages. I don't have any more thought on it than what I just gave you.

[Josh Raskin, Nephron Research]

And just one quick call on the revenue guidance, is there an assumption of pass-through revenues that are going to be coming through? Or is that in the bucket of COVID impact that we're not anticipating?

[Joe Zubretsky, President, CEO & Director]

I'm not sure I understand are you referring to a Medicaid? And I'm not sure what you're referring to exactly, Josh.

[Josh Raskin, Nephron Research]

Yes, Medicaid payments where you're going to see increases to the provider fee schedule they get passed through in terms of Medicaid.

[Joe Zubretsky, President, CEO & Director]

I think it's possible. I will answer the question more broadly. Most of our state customers are very concerned with the viability of various aspects of the medical communities in their states. And whether it's going to be enhancements to the fee schedule request, as you've seen, to pay claims faster, in some cases, even advanced payments to small providers, they are very focused on the health of the provider system. But we have not seen yet, from what I've been exposed to, any major changes to fee schedules. But there are many conversations ongoing about how to keep the providers funded during this entire process.

[Josh Raskin, Nephron Research]

Thank you.

[Operator]

The next question comes from Sarah James of Piper Sandler. Please go ahead.

[Sarah James, Piper Sandler]

Thank you. I wanted to circle back to your comments that in a strong economy, Medicaid rates are set at the high end of actuarial soundness and in the recession, will be set at the low side. Can you give us more detail what is that meaningful margins when you think about the peak to trough move?

[Joe Zubretsky, President, CEO & Director]

I think the first thing I would say, Sarah, is we put a lot of faith in the concept of actuarial soundness, there's ebbs and flows. There's constant tension when benefits are carved in, when the benefits are carved out, when new populations are attempted to be capitated. There's a constant ebb and flow. And the only point we are making is if from a business model perspective, you would expect that in very strong economies when tax revenues are flowing, that rates would be on the strong side of actual soundness and the opposite could be true when tax revenues are down, in terms of recession.

But the concept of actuarial soundness has proven in this industry. It's proven in the years that I've been here as testament to the margins that we're achieving. There are ebbs and flows. And all I'm suggesting is that in a recession, we could expect rates to be on the softer side of the actuarial soundness concept. But we still have not changed our outlook for our target margins, but a lot needs to be seen here in terms of what trend figures are going to be baked into the 2021 rates. Are we going to use normalized trends off of 2019?

So when trend is inflecting the way it is, I think the bigger issue is when trend is inflecting up and down the way it is, how are the actuarial teams and our state customers and the actuarial teams of the managed care industry going to reconcile the various views of medical cost trend when we go to look at 2021 rates. But all that being said, I have a lot of faith and confidence in the actuarial soundness concept because it's actually worked well for managed Medicaid.

[Sarah James, Piper Sandler]

That's very helpful and comforting given how strong the relationship is with the state actuaries as medical trend does change. So just one more follow-up there. You mentioned that one of the possibilities could be items being carved in and carved out. Can you provide us any color on your discussions with states on how they're viewing the shape of their program, given where their budgets may be?

[Joe Zubretsky, President, CEO & Director]

Sure. The one aspect of managed care and medical cost in managed care that comes to mind in your specific question is related to pharmacy. As you know, that is commonly discussed as to either be carved in or carved out. As you probably saw in the New York state budgetary process that was just finalized they have suggested that at some point in the future, New York State could carve out pharmacy.

Obviously, not terribly material for us with a $200 million business there, but carving in and carving out is actually, in my view, more of a question of how much rate how much capitated rate do they put in or take out. We'd rather see it bundled into the full capitation and have more revenue. But if it's carved out, it's if they carve out on an unsubsidized basis, you lose your 2% margin on what's carved out and that's it. So you just you hope through the negotiating process that the proper amount of capitated rate is either carved in or carved out. That's the issue, in my opinion.

[Operator]

The next question comes from George Hill of Deutsche Bank. Please go ahead.

[George Hill, Deutsche Bank]

Yeah, good morning, guys and thanks for taking the questions a lot been covered. A lot has been covered. I guess, Joe, kind of a follow-up on the Magellan deals. As you think about the M&A environment, do you expect kind of the current environment that we're going into now to kind of make M&A more difficult or less difficult trying to figure out if people are targeting Medicaid enrollment to kind of defend smaller businesses and smaller plants, making them harder to acquire? Or could people see this as an opportunity to exit? And I have a quick follow-up for Tom.

[Joe Zubretsky, President, CEO & Director]

Interesting question. I think most of the investment banking community would tell you that in the past couple of weeks or months, that many of in-flight processes have stalled. This one's been going on for some time. And so it was able to get done with great cooperation from the guys from Magellan, and the teams worked well together. It's hard to say. I think this business is a tough business.

And we look at some of the smaller players, the not for profits, the single state players, it's hard to get the operating leverage, the scale, the clinical resources you need to actually do a good job. It's just a tough business. But when this is all you do, and you have 3.5 million members and $20 billion of revenue, we certainly have the investable base, the skills and resources to be well here.

So buying underperforming properties at 30% of revenue, getting the EBITDA margins up to 6%, 6.5%, that is a great use of our resources and our skills. Particularly when they're funded with cash that's generated from core operations, and we don't have to go to the equity markets or even the debt markets to fund them. So here in the foreseeable future. Obviously, we're going to be working on the regulatory process with Magellan, then we'll be integrating it. But we're still going to look for these single area bolt-on, tuck-in opportunities like the YourCare acquisition, which is fabulous for us. We're going to continue to look for them because we actually have the cash flow to action on them if they're actionable.

[George Hill, Deutsche Bank]

That's helpful. And I guess, Tom, my quick follow-up for you is an accounting one, which is I know it's early, but if we start to think about the contracts where you guys have MLR minimums. I imagine at some point you'll have to reserve against revenue or have contra revenue accounts for what could be premium rebates or premium holidays. Have you guys started to do that yet? And is it too early to think about or discuss what the magnitude of that could look like?

[Tom Tran, CFO & Treasurer]

Good question there. And we do that consistently every quarter. As you know, in our marketplace, we have to provide reserve for potential rebate based on certain forecasting of the eventual medical care ratio. And we do the same thing for our Medicare line of business. And we will be doing the same thing for Medicaid, should that happen to be the situation.

[George Hill, Deutsche Bank]

Okay. But I guess, no way to kind of quantify what the incremental could look like from normal versus kind of what we're stepping into the next couple of quarters?

[Tom Tran, CFO & Treasurer]

No. No. As we said in our prepared remarks, the volatility of this impact on from COVID on the impact on medical costs is unknown. That's why we hesitate to provide more color on that. So we'll have to let this thing play out over the next couple of quarters. And it's typically done based on either a calendar year or contract year depending on how the state prescribed that.

[Operator]

The next question comes from Dave Windley of Jefferies. Please go ahead.

[Dave Windley, Jefferies]

Hi, good morning. Thanks for taking my questions. Joe, you always have a great ability to cut right to the chase. My question is around operating Medicaid managed care organization in a COVID environment, thinking about a couple of transactions you now have in-flight that include New York operations at the center of COVID. So just interested in kind of understanding how you might see the future change in one's ability, the risks and opportunities in managing a plan in a cohort effected environment given that you seem willing to step right into the epicenter with both of these acquisitions, YourCare and MCC having significant operations in New York.

[Joe Zubretsky, President, CEO & Director]

Thanks for the question. It's look, it's a challenge. We moved 6,000 people from working in office to working at home. There are, as I said, hundreds of requests we're getting from regulators every day to do certain things. That requires you have to reconfigure your provider contracts. I mean the operating protocols and the amount of operational change that we're going through right now and dealing with all this is significant.

But in New York, our business is in upstate New York, which is not the epicenter of COVID, but certainly is being impacted. The MLTSS business in New York is a good business. We managed $2 billion of LTSS benefits nationwide. I think we're the largest or the second largest manager of LTSS benefits. So it fits nicely with the portfolio. It's really it's not a medical business, per se.

It's a business where we cater to the activities of daily living to pretty complex members under the Medicaid program. But it's a good business. It's got seven over $700 million in revenue. It's reasonably profitable. We think we can enhance the profitability by managing the hours more effectively. But COVID-19 was certainly a consideration as we actioned it. But we're either COVID-19 will either have abated by the time we own it or be so well understood and well managed, that it will be the new normal. So it was a consideration, but it did not deter us from wanting that property and including it in the purchase.

[Dave Windley, Jefferies]

Great. On exchange, you commented that you haven't really seen a material change in trajectory on membership there. Maybe that changes. Does that influence the what is likely to happen this year, influence the way that you will address your growth strategy in that business for 2021 after the 2020 kind of positioning didn't pan out as you thought it would?

[Joe Zubretsky, President, CEO & Director]

It's a very good point. I will expect in the question, I will reiterate that our strategy hasn't changed. We had committed to growing the pool of profits of the exchange business. And had articulated that we will make the local geographic call as to where to push price for gaining membership and where it ease on or where to push price to gain members push price down to game membership, and we're ease up on it to gain margin and make local decisions based on competitive forces.

And obviously, as you suggested, and admittedly, we got the elasticity of demand equation long last year. The bigger issue for us. So the strategy hasn't changed. We're going to take the full profits and attempt to grow it over time at reasonable margins. The rent that's been thrown into the works, obviously, is coded. Right now, as we sit here today, we're developing the pricing model for 2021. They're off of the 2019 baseline, which is pure of COVID. But the question will really be, what type of rates go into the market for 2021, given the COVID environment that we're in right now?

So our belief is that in discussions with regulators, allowances will be made for maybe some later rate filings, maybe rate filings that include COVID and others that don't. Allow us to see more so that we can take a reasonable view of medical cost trend, getting into the rate so that we're not guessing, and the industry is not guessing. We don't want to push so much rate into the market that we have excess margins, and we certainly don't want to undercut it to where margins are too low. We want to get it right. So we're working with the regulators right now on the pricing regimen for 2021.

[Dave Windley, Jefferies]

Got it. One last one, if I could. What level of cash do you want to have liquidity, do you want to have to run the business? And are you willing to add more leverage in this environment?

[Joe Zubretsky, President, CEO & Director]

Our leverage position is very strong, and I would encourage people not to look at our debt to total cap, which averages 40% to 45%, I think, it's 46% at the end of the quarter. Because that generally just sounds high to people. Our debt-to-EBITDA coverage is 1:1. Our leverage is 1:1. Our fixed interest cost coverage is like three weeks of earnings. We've covered our fixed charges and interest. So we're actually underlevered from a cash flow perspective.

Having said that, in this environment, you always want to be more liquid than you otherwise would, but with $840 million of cash, $500 million of dividends expected this year, $900 million of untapped facilities, we believe we still have enough cash and enough liquidity cushion that have another bolt-on acquisition opportunity came up this month, next month or next quarter, we'd be able to action it. But in this environment, you want to be a little more liquid than normal. We usually target $100 million of parent company cash as a floor, and we'd probably think slightly higher than that in this environment

[Operator]

The next question comes from Ricky Goldwasser of Morgan Stanley..

[Unidentified Analyst]

This is Alex [ph] actually in for Ricky. First question, I just have two. One is just following up on George's question about M&A. So you talked about how Magellan is kind of a year-long for to close so could you give some color just on the typical time line to get your deals ready to announce? And how many kind of companies that you're looking at, at any given time?

[Joe Zubretsky, President, CEO & Director]

Well, without getting into the process because that's we don't really want to do that. But the point what we wanted to make was that this efforts or long predated coped when the process started. And that was the only point we're really making. But willing buyer, willing seller, it's hard. There's a lot of properties out there, and many of them aren't actionable. But getting something that strategically fits from a product and geography perspective, and then one that's actionable is hard work. We have an expert M&A group, led by Mark Keim and a great team of people who are scanning the universe for actionable opportunities that fit with the portfolio and that are actionable. And last year, we found YourCare, we found NextLevel, but we obviously terminated our agreement with the NextLevel for very good reasons. And then this opportunity came into the market, and we worked it really, really hard with great cooperation from the folks from Magellan. There are others in the pipeline. I can't mention what they are and where they are, but there are still properties out there that are actionable, and we still have the liquidity and the resources to action them if, in fact, they come to market and can be actioned.

[Unidentified Analyst]

That's helpful. And then just on the deferred elective care side. We've heard ranges over the last week, about 15% to 40% of total medical costs are associated with elective care. Is there anything that you can give us on how your elective costs compare to your book?

[Joe Zubretsky, President, CEO & Director]

Sure. It's hard to draw any conclusions from two weeks in March, but we certainly could draw conclusions from the full month of April. On the outpatient and professional services side, outpatient and ambulatory surgeries, depending on the geography line of business, pre authorization requests and notifications down 30% to 50%. Diagnostic testing and imaging, another sort of elective category, 40% to 45% PCP referrals to specialists, DNA, all down significantly over comparable periods.

We're a seeing it on the inpatient side, particularly with elective surgeries and even in behavioral services. So in the medical cost categories that tend to be elective and discretionary we're seeing pre authorization requests and notifications down significantly over comparable periods. The other point I would make here is how long does this persist? There are various mandates of the suspension of elective procedures. That can't be done under either state authority or governmental authority that will end soon at some point.

But there will be a contagion of fear of patient fear of going into facilities for the risk of being infected. So how fast they rebound, how fast the boomerang effect and when they come back, is another factor and why predicting what medical costs look like here over the next three to six months is difficult. I remind everyone, when we're talking about the rebound factor is there's a capacity limitation on how fast things can rebound.

There are only so many beds. There are only so many doctors, and there's only so many hours in a day. And when you have three, four, five or even six months of pent-up demand, it cannot race through the pipe that quickly. There's a capacity limitation on how fast it rebounds, which adds another variable into forecasting how quickly this could rebound. So I hope that helps, but that's sort of a view of what March and April looked like from an elective and discretionary procedure outlook.

[Operator]

The next question comes from Charles Rhyee of Cowen. Please go ahead.

[Charles Rhyee, Cowen]

Yeah, thanks for taking quite not just to make just maybe two quick questions for me here. Joe, you talked about potential delays of decisions. But you still said you expected Kentucky sometime in the second quarter. So are you still expecting Kentucky to make a decision in the second quarter? Or do you think that is upward delay?

[Joe Zubretsky, President, CEO & Director]

We've been told that actually, we were told month of May, but we wanted to just open it up in the second quarter because we just weren't sure. But we've actually originally, they actually posted that they were going to do it in April and then due to COVID-19, they actually then pushed it. And whether it's actually published in writing or they made an announcement, I can't recall. But they did say May, but we sort of opened it up and said sometime in the second quarter. So we haven't heard about a suspension. And until we hear otherwise, we still expect the second quarter announcement.

[Charles Rhyee, Cowen]

Great. And then, Joe, at the beginning, you kind of also mentioned about some of the things you are doing for your members, including opening access for Telehealth. And we saw the announcement, obviously, several weeks back about using Teledoc. Can you just help us understand a little bit how Telehealth is priced for a Medicaid population when you extend it to your members? Is that should we think about it in the same way as for commercial population that the members are paying some dollar visit fee? Or is that something that you guys include in sort of the overall cost that you're charging to state?

[Joe Zubretsky, President, CEO & Director]

The first thing I would say to that is in our company, our Telehealth solution is more fully implemented in our Marketplace product than it is in our Medicaid product. It is beginning to be rolled out in our Medicaid product. And obviously, this accelerated the rollout because it was the right thing to do and members couldn't get in person visits. As we said in our prepared remarks, we created a parity mechanism between in-person visits and Telehealth visits. But I wouldn't want to say how it's priced, but it's more penetrated as we're searching for in our Marketplace book, than our Medicaid book. And we have a contract, we pay for it, and it's loaded in the benefit, is really all I can say.

[Charles Rhyee, Cowen]

I understand that. I mean I guess, is there a cost sharing then? Do members pay some amount to access it like they would in a commercial population? In a more typical commercial population? Or is it done differently? I guess...

[Joe Zubretsky, President, CEO & Director]

Well, generally, in Medicaid, the members are not paying anything out of pocket for any service. So in Medicaid, the answer is no. And I believe I'll project this and get back to you. But in Marketplace, it's probably like any other claim payment. If somebody's decided they're deductible, it gets treated that way. If there's a co-pay whatever the benefit plan is, I think it gets treated just like another claim pursuant to the benefit structure of the contract.

[Charles Rhyee, Cowen]

Okay, thanks, that's it. Really helpful.

[Joe Zubretsky, President, CEO & Director]

Thank you.

[Operator]

As there are no further questions, this does conclude our question-and-answer session. The conference has now also concluded. Thank you for attending today's presentation. You may now disconnect.