Good morning. My name is Bhavesh [ph], and I will be your conference operator today. At this time, I would like to welcome everyone to Oscar Health's Fourth Quarter and Full Year 2023 Earnings Conference Call. At this time, all lines have been placed on mute to prevent any background noise. After the speakers' remarks, there will be a question-and-answer session. [Operator Instructions] Thank you. I will now turn the conference over to Chris Potochar, Vice President of Treasury and Investor Relations.

Good evening, everyone. Thank you for joining us for our fourth quarter and full year 2023 earnings call. Mark Bertolini, Oscar's Chief Executive Officer; and Scott Blackley, Oscar's Chief Financial Officer, will host this evening’s call. This call can also be accessed through our Investor Relations website at ir.hioscar.com. Full details of our results and additional management commentary are available in our earnings release, which can be found on our Investor Relations website at ir.hioscar.com. Any remarks that Oscar makes about the future constitute forward-looking statements within the meaning of Safe Harbor provisions under the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by those forward-looking statements as a result of various important factors, including those discussed in our quarterly report on Form 10-Q for the quarterly period ended September 30, 2023, filed with the SEC and other filings with the SEC, including our annual report on Form 10-K for the period ended December 31, 2023, to be filed with the SEC. Such forward-looking statements are based on current expectations as of today. Oscar anticipates that subsequent events and developments may cause estimates to change. While the company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so. The call will also refer to certain non-GAAP measures. A reconciliation of these measures to the most directly comparable GAAP measures can be found in the fourth quarter and full year 2023 earnings press release, available on the company's Investor Relations website at ir.hioscar.com. With that, I would like to turn the call over to our CEO, Mark Bertolini.

Thank you, Chris. Good morning, everyone. When I joined Oscar, I highlighted three priorities for the business. One, achieve insurance company-adjusted EBITDA profitability in 2023. Two, achieve total company adjusted EBITDA profitability for 2024. Three, continue to enhance the value of our technology to the +Oscar business and bring more of our capabilities to market. We have made major progress toward achieving these priorities. We closed out 2023 with another strong quarter, driving financial performance for the full year and achieving the first of our priorities. The insurance company generated $169 million of adjusted EBITDA profitability in 2023, a milestone Oscar committed to in early 2022. Our medical loss ratio improved 370 basis points year-over-year to 81.6%, below the low end of our guidance range. For the full year, overall claims trends were favourable relative to our expectations. Utilization trends by category remained consistent throughout the year with inpatient performance in line, outpatient and pharmacy slightly above, and professional well below. Total company adjusted EBITDA improved by $417 million versus the prior year to a loss of $45 million. Our strong momentum positions us well to achieve the second priority I mentioned, total company adjusted EBITDA profitability in 2024. Our business is well positioned for sustainable long-term growth and margin expansion. We exceeded our 2024 open enrolment expectations and expect to serve over 1.3 million members. We continue to see strong retention, which we believe is driven by our superior member experience. Our disciplined pricing in 2024 is allowing us to grow our membership well above the market, while driving margin expansion. We expect another year of MLR improvement, given our pricing strategy and total cost of care initiatives, including significant PBM savings and enhanced payment integrity efforts. We also anticipate continued operational cost improvement, including vendor savings from our…

Thank you, Mark, and good evening, everyone. We delivered strong financial results in each quarter of 2023, with most core metrics exceeding our expectations for the full year. We delivered on our commitment for insurance company adjusted EBITDA profitability in 2023 and have a clear line of sight into achieving total company adjusted EBITDA profitability this year. I will touch on a few fourth-quarter highlights before shifting to our full-year performance. We had a strong close to 2023. Our fourth-quarter medical loss ratio significantly improved by 520 basis points to 86.4%, and our fourth-quarter total company adjusted EBITDA loss was $112 million, a $78 million year-over-year improvement. We ended the year with approximately one million members. Membership increased 5% quarter-over-quarter, driven by higher retention due to lower lapse rates and increased special enrolment additions. Turning to the full year; direct and assumed policy premiums were approximately $6.6 billion, a 3% decrease year-over-year, and modestly above the high end of our guidance range. This was driven by lower membership, partially offset by rate increases. The full-year medical loss ratio was 81.6%, a 370 basis point year-over-year improvement and below the low end of our guidance range. Overall utilization trends were modestly favourable relative to our expectations for the full year, and we delivered medical cost savings through our total cost-of-care initiatives. As Mark mentioned, utilization trends within specific service categories remained consistent throughout the year. On risk adjustment, our risk transfer as a percentage of direct and assumed policy premiums for 2023 was lower year-over-year at approximately 14% due to our member profiles having shifted closer to the overall ACA population. The December weekly report resulted in only modest updates to our risk transfer estimates. Switching to administrative costs; the 2023 insurance company administrative expense ratio improved 270 basis points year-over-year…

Thank you, Scott. I would like to close by looking back at the financial metrics we shared with analysts in connection with Oscar's initial public offering in 2021. We said we expected to achieve the following in 2023, nearly one million members, $5.7 billion in direct and assumed policy premiums, an 83% MLR and a total company adjusted EBITDA loss of $222 million. Today, Oscar has far exceeded these metrics. We are a prominent player in the fastest growing segment of health insurance. We demonstrated the power of our superior member experience and technology by exceeding our projections for open enrolment. We achieved insurance company profitability and outperformed our expectation for total company adjusted EBITDA in 2023. We are returning to growth and have a clear line of sight into delivering on our target for total company adjusted EBITDA profitability in 2024. We have done what we said we would do. Oscar is delivering on its commitments. I would like to thank the Oscar team. We are powered by our people, their hard work and dedication make all of this possible. With that, I would like to turn the call over to the operator for the Q&A portion of our call.

[Operator instructions] Our first question comes from the line of Adam Ron of Bank of America. Please go ahead.

Hey, guys. Congrats on the strong results. In thinking about the adjusted EBITDA trajectory from here, you're on track to do something like 2% from a margin perspective in 2024 and I think in the past, you've talked about total company, maybe on a pre-tax basis, being closer to 5% and so the difference between those two things is still roughly 300 basis points to 500 basis points of margin improvement and this year was sort of outsized from a revenue growth perspective and so, what do you see as the major levers in terms of being able to close that gap between the 2% adjusted EBITDA and 5% pre-tax margin given you probably shouldn't expect to kind of like 40% revenue growth here from here and maybe some of the lower hanging fruit around PBM contract renegotiation aren't as readily available and so, just thinking about what the major levers are from here would be helpful.

Thanks, Adam. Mark Bertolini here. We'll start with big categories. First, we have enough fixed costs to grow to a much larger size. So fixed cost leverage will be pretty robust. No matter how much we grow, although we anticipate and continue to anticipate that 20% growth year-over-year is achievable. Secondly, we have in our variable operating expense been able to leverage large language models on the back end of the system and just for an extra data bit on our call volumes, we actually handled the call volumes we had this year with 200 less people answering the phone. So we continue to see big operating opportunities on the variable cost side. We are in the midst of looking at provider contracts, particularly hospital contracts, and we now have a matrix of contracts that we need to get to optimal level from the standpoint of both terms and rates and so we have a list based on renewals and market size where we're going to begin those conversations with our provider partners, not just because we have more market share, but because we have better relationships with them in the way we deal with them day in and day out on utilization management and on reimbursement and paying claims. Scott, anything to add?

Yeah, Adam, I think that, we certainly think there is room to run in terms of continuing to drive MLR performance through discipline pricing and we see continued opportunity to drive total cost of care down, allowing us to both grow and to take margin. Mark talked about admin efficiency. I think there's also plenty of room for us to continue to drive favourable performance there. And then I think that just broader speaking, we really believe that this market is going to continue to attract individualized consumers and that's where we really shine on building innovative plans and if we can continue to see that development in the market, we think that we have a terrific opportunity to continue to grow the company. Obviously, fixed cost leverage is going to be our friend. So we think we've got all the bones in place to get to that over time.

Awesome. If I could just sneak one more in, maybe more shorter term; both CVS and Cigna have been seeing, somewhat varied performance on these changes as opposed to you, Centi and Molina and I think CVS in particular has been complaining about, the special enrolment charges or, having less than opportunity to risk code members who join in the middle of the year and that's something that, Oscar has struggled with in the past, but doesn't appear to be impacting results this year and so you could just, square that commentary of, like, are you seeing outsized pressure from the mid-year enrolment dynamic and does that argue that core MLR results are higher than what's been reported and does that -- is that how we should contemplate 2025 MLR improvement from here? Just wanted to understand the varied performance versus some of your competitors. Thanks.

Look, I think that we've been experienced SEP for years. We certainly understand the dynamics of how duration factors impact those members. We build that into our price assumptions. This year, we've seen SEP members that have performed, you know, more or less consistent with our historical experience with them. So, nothing for us that has caused us any challenges in terms of onboarding those members. With respect to 2024, we assumed that we would be growing the SEP membership would come in into the second half of the year and we built that into our guidance for MLR. It's an area that's challenging, certainly, but we've got experience there. We've got, I think a reasonable expectation of how those members are going to perform based on what we've seen through the end of the year and into this year and they have a morbidity profile that is kind of what we're expecting. So, there's always some risk with growth and with new members, but we think that we've built those risks into the guidance that we gave you today.

Our next question comes from the line of Josh Raskin from Nephron Research. Please go ahead with your question.

Hi, thanks. Good evening. Do you think the stability of the exchanges and certainly the growth that we're seeing in the market is attracting, sort of these new larger competitors? Are you seeing, overall rational behaviour from them and how lasting do you think the competition is?

I would say that rational behaviour was not necessarily in place last year and I would in 2023, open enrolment for 2023, in large part because people have not priced accordingly to how the market works. As you well know, and part of what we found, even when I was with Aetna in the markets is that the minimum loss ratios that were put in place for pricing don't allow you to underprice and then price up business after you get share because you have to give back rebates. And so, this going into with a mindset that we will grow with disciplined pricing is an important piece and we saw some of that this year for 2024 open enrolment where people took their prices up, lost the business and, Georgia is one of those markets. And when we look at our rates in those markets, we are where everybody else is now pretty much with increases that are in the 8% to 9% range. So, we felt that we go into this with an open eyes and deep understanding of this market over time and we believe that we have priced accordingly and have been disciplined about it; stable and rational pricing.

Got you. And then just secondly, midpoint of EBITDA guidance of $150 million at the whole co level; what does that mean for cash flow from operations and can you just help us with the moving parts on the parent cash balance for 2024 and I sort of thinking about the Florida capital that's not needed sort of versus the growth. I'm just trying to figure out, what we should be thinking about cash from operations and then what does that mean for parent cash?

Yeah. So, Josh, I think that the importance of the adjusted EBITDA metric for total company is that, that would with the growth, we'll be getting additional cash, prior to paying the risk transfer estimate. So, we would anticipate that the total company will be cash flow positive, will be building capital in our insurance subsidiaries and in terms of those subsidiaries, what we would be looking to do going forward is prioritizing; one, funding to growth that we hope to continue to have; two, distributing capital to the parent to offset parent expenses and three, that they will be absorbing more of the holding company costs over time. So, we feel like we've got a good situation with capital and cash and would expect to be cash flow positive next year, or excuse me, in 2024.

Our next question comes from Nathan Rich from Goldman Sachs. Please go ahead.

Great. Good afternoon and congrats on the strong quarter. I maybe wanted to start by asking if you can maybe break down the composition of membership growth a little bit more between markets that, maybe you entered for 2024 versus growth within existing markets and you also talked about a healthier membership base. Could you maybe just expand on what you're seeing there?

\Yeah. Well, why don't I start and then, Mark, maybe talk about some of the membership growth, but overall, when we look at the demographics and kind of the morbidity of the group that we're seeing, I would characterize it as, number one, it's younger and so, we certainly with this growth have seen, younger members coming in more than a little more than a year younger in terms of the total population. Number two, I would characterize it as we've seen a shift of more of our membership in 2024 towards bronze or excuse me, from bronze to silver and so that is another dynamic that we've seen. Overall, I would say that our membership being healthier is representative of the fact that we think we're going to have a higher risk transfer this year. So, the dynamics of that membership, younger, healthier and in silver plans are probably the things I would kind of point out. Mark, do you want to cover the state by state?

Sure. Strong retention was the biggest part of our growth, I would say that and also provide stabilization and risk adjustment as we go forward into this year. It was obviously helpful for us last year. We did grow new members in existing markets, Georgia, Florida, Ohio, Tennessee, Iowa and Missouri, but we also outperformed expectations in new markets where we did some service area expansion, Cincinnati, Tennessee and some of the rural markets in Iowa and Georgia.

Great. And maybe just a quick follow up. I think in the past, the company has talked about a target MLR in the low 80% range. You pretty much got into that level for 2024. So I guess, as we think beyond this year, do you think there's still kind of improvement in the MLR that can be had or will more of the margin expansion, I guess, come from leveraging growth that you might see?

We definitely have room in the MLR.

Just to even put a fine line on that. Remember, our PBM contract has year-over-year step improvements that are built into that contract. So without doing anything, our pharmacy costs would be lower in 2025. So a lot of the things that you're seeing in the run rate that's benefiting '24, we would anticipate have incremental improvements in the '25 and, we would expect to continue to drive down the costs of healthcare.

[Operator instructions] Our next question comes from the line of Stephen Baxter from Wells Fargo. Please go ahead.

Hi, thanks. I'm just wanted to follow up on, the PBM discussion. I know in the past you talked about the savings being spread out over 2024 and 2025. So good to hear some of that still in front of you. Can you give us a sense of maybe what you mean we're in the PBM savings exit in 2024? And then just a second on, kind of the profile of membership you're looking for in 2024. Just wondering, it sounds like now that you've gotten to insurance company profitability, I would think that growth that you're seeing from inside the open enrolment period, would seemingly come on at incremental profitable margins, but perhaps you're taking a more conservative stance to start out. So we'd love some insight into how you're thinking about the profitability of the growth and then just last one, exiting this year, where do you think you'll be on some of the payment integrity efforts that you've talked about in the past? Thanks.

I'm going to try to remember all those. So if we miss one and I'm not being, please, please come back. So, when I think about where we might be going from a overall, starting with kind of the MLR, I think there's opportunities there around the PBM, where the PBM actually goes out till 2026 and so we have, a contract where each year we will see benefits and this was the -- first year was the largest step change, but there's continue to be meaningful improvements in that contract over the remaining term. So that is -- that's something that, we can put in the bank and we're pleased with our partnership there with our provider.

And I would add that we also have the opportunity for volume -- more volume, that's just more discounts than we initially anticipated and then thirdly, there's an opportunity to work on the MAC list quarter after quarter. On the payment integrity issues, we'll see full year effect on what we've done for last year, this year, but we have more to go this year. So we'll continue to improve upon those, particularly as we apply AI models to the back of the business and go after things that we now pay vendors for. And then I think, last but not least, we still have a lot of provider relationships that we can affect in markets that were vintage markets where the company started, had no volume and was able to move on those medical costs. So we have room on medical costs across the board.

And then Steve, probably the last piece on your question on member economics, I would say that we would anticipate that, you know, all of the growth that we're seeing in open enrolment is contribution margin positive. So at this point, growth is great for the bottom line. We also expect to see continued enrolment through the special enrolment period and while those members come at -- we talked about this in the past, with about a 10% higher MLR and there are the durational impacts that we talked about, that's in the first year and then they, look exactly like the rest of OE if we can retain those people. So, it is certainly the case that depending on when you get those members in the year, the economics can be challenging in the first year, but we built that into the plan. So those are already built into our guidance and we are excited to have the opportunity to add more members through special enrolment period in addition to the success that we've already had in open enrolment.

Okay. Thanks for the color.

Thank you. Our next question comes from the line of Adam Ron of Bank of America. Please go ahead.

Hey, thanks for squeezing me back in. I just have one more question. I get a lot of questions on the Affordable Care Act subsidies, and there are some government estimates out there of, if the subsidies were to go away, what would happen to the market size and so just wondering, one, if you have any comments on what you'd expect it to do to the market, maybe relative to like what your mix of members look like relative to who is using the APTCs. So first on that, and second, you mentioned before you look at G&A as fixed variable, like maybe this would be a helpful framework for us of, if we're able to think about how much of the G&A is fixed variable, how that would flow into earnings. And then finally, if there, if the subsidies were to go away, which obviously nobody can predict, is it fair to say that margin would degrade, or is there a reason to believe, there's some levers you could pull to kind of offset that? Thanks.

Well, the last part of your question, Adam, we believe that we have an opportunity to provide services at a different price point that could help folks when and if the enhanced subsidies go away. But going up to the more general level, will they, we had some interesting looks at our data this open enrolment, and in this open enrolment, 63% of new ACA consumers are from red states and 76% during the open enrolment and year-over-year in the ACA, our market growth is in red states. So I kind of find it hard that the political dynamic that was going on six, eight years ago is going to be the same relative to the Republican Party, going after a group of people that largely are going to be their own constituents. We'll see. We have a planning version on our strategic plan of having it go away and all the things that we would need to do with product in order to make things affordable. Folks in the group we worry about most are the people in the 100% to 200% federal poverty level that have zero premium plans, and would potentially be paying somewhere around $60 or $70 a month. That's the place where we think the impact is, and we're planning against that to find solutions for it. Relative to fixed versus variable, Scott, I'll let you decide.

Yeah, look, on fixed versus variable, I think that's information that we will look forward to sharing more about with you when we have our Investor Day in June.

Awesome. Thanks again.

Thank you, ladies and gentlemen. As we have no further questions at this time, we will conclude today's conference call. We thank you for participating, and you may now disconnect.