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.

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?

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…

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…

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

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?

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?

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?

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.

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

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?

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.

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?

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?

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

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?

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.

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?

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.

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?

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.

It's great, thanks.

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

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.

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.

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?

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.

Thank you.

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

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?

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.

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.

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.

Thank you.

You're welcome.

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

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.

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.

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?

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.

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?

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

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

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.

Thank you.

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

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?

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.

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?

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.

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

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.

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.

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?

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.

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?

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.

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

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.

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.

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?

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.

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?

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

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

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?

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.

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?

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.

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

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?

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.

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?

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.

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...

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.

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

Thank you.

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.