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Centene Corp (CNC 0.46%)
Q4Â 2019 Earnings Call
Feb 4, 2020, 8:30 a.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Good day and welcome to the Centene Corporation 2019 Fourth Quarter and Year-End Results Conference Call. All participants will be in listen-only mode. [Operator Instructions] Please note this event is being recorded.
I would now like to turn the conference over to Ed Kroll, Senior Vice President, Finance and Investor Relations. Please go ahead.
Edmund Kroll -- Senior Vice President, Finance and Investor Relations
Thank you, Brandon, and good morning, everyone. Thank you for joining us on our fourth quarter and full year 2019 earnings results conference call. Michael Neidorff, Chairman, President and Chief Executive Officer; and Jeff Schwaneke, Executive Vice President and Chief Financial Officer of Centene, will host this morning's call, which can also be accessed through our website at centene.com.
A replay will be available shortly after the call's completion also at centene.com or by dialing 877-344-7529 in the US and Canada, or in other countries by dialing 412-317-0088. The playback code for both dial-ins is 10138090. Any remarks that Centene may make about future expectations, plans and prospects constitute forward-looking statements for purposes of the safe harbor provision under the Private Securities Litigation Reform Act of 1995.
Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors, including those discussed in Centene's most recent Form 10-Q and Form 10-K and other public SEC filings. Centene anticipates that subsequent events and developments will cause its 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 with the most directly comparable GAAP measures can be found in our fourth quarter and full year 2019 press release, which is available on the company's website at centene.com under the Investors section. A reminder that Centene will host its first quarter 2020 earnings call on Tuesday, April 28th, 2020.
And with that, I'd like to turn the call over to our Chairman and CEO, Michael Neidorff. Michael?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Thank you, Ed. Good morning, everyone, and thank you for joining Centene's fourth quarter and full year 2019 earnings call. I'd like to apologize now for any residual cough you may hear as a result of some bronchitis I had a week or so ago. Before I go through our 2019 results, let me say how pleased we are to have closed the WellCare transaction on January 23rd.
We were cautiously optimistic that the transaction would close early in the first half of 2020, and we are happy that this was the case. We are now a $100 billion-plus enterprise providing healthcare services to more than 24 million members across all 50 states, or one in 15 individuals across the nation. Having achieved this, we still have a long runway ahead of us with enhanced scale, further diversification of products and capabilities, and greater opportunities for growth across portfolio.
As we have previously disclosed, our planning assumption was to be ready to begin the integration by January 1. I am pleased to report that the integration process is well under way and teams are managing the various work streams. For example, we have begun to align 2021 bids for our Medicare business. In addition, we have activated integration plans in markets. We welcome in [Phonetic] Centene overlap such as New York, Georgia and Florida. We remain on track to achieve our previously committed and communicated accretion and synergy targets. Most importantly, we are happy to welcome the WellCare team and colleagues to Centene.
Let me now turn to a recap of Centene's 2019 highlights. 2019 was another robust year for Centene. We delivered strong top and bottom line growth, enabled by operational and commercial successes across our enterprise. We remain focused sticking to our business as usual approach. We were not distracted by the significant headline noise during the year. We continue to execute against our strategic priorities and invest in capabilities that have positioned Centene for long-term success. In 2019, we added 1.1 million members, representing growth of more than 8%, surpassing a 15 million member mark. This growth was achieved in the face of seat eligibility redeterminations, which continued to moderate. We continue to grow our market-leading position in both Medicaid and the ACA marketplace.
We grew revenues by 24% to $74.6 billion and adjusted earnings per diluted share by 25% to $4.42. The HBR increased 140 basis points to 87.3%, driven by normalized margins in the exchange business relative to favorable performance in 2018 in the health insurer fee moratorium. The adjusted net income margin increased 10 basis points to 2.6%. We continue to execute a smooth and seamless integration of Fidelis, the only remaining task in this process is to finalize the incorporation of Fidelis onto our claims systems platform. We also continue to invest in strengthening our products and capabilities with a focus on areas that will complement our core business, enable us to continually enhance how we impact patient outcomes while delivering long-term care.
A few highlights. We achieved meaningful progress with Centene Forward, an important initiative that we expect will better position Centene for long-term growth, increased margins and profitability. In 2019, we executed a more than $500 million in initiatives. And the program has now evolved into a permanent part of Centene's and the company's organization and culture. We continue to migrate our membership to RxAdvance, a technology-based pharmacy platform, which enhances quality and transparency while lowering costs. We continue to focus on proof-of-concept, and we'll expand as appropriate.
We increased our stake in Primero Salud from 50% to 90%. This demonstrates our commitment to continue developing Centene's international portfolio. We are also proud of the initiatives we announced in 2019 to enhance the health of the communities we serve. I would like to highlight just a few.
In February, we formed the Social Health Bridge Trust to help organizations more effectively address the social determinants of health. In April, we launched the OpiEnd Youth Challenge to raise awareness among adolescents about opioid misuse and prevention of dependents. And in September, we launched the Food For Today and Food For Tomorrow development initiative with Feeding America to help those experiencing food insecurity. These initiatives are all in line with our whole health focus, an integrated and holistic approach to how we work with our community. We will focus on addressing the broad range of social determinants of health.
For example, Medicaid volumes are particularly likely to struggle with non-medical barriers to health, including nutrition, education, transportation and proper housing. As a leading multinational managed care enterprise, we will continue to lead initiatives and partner with organizations to transform the health of communities across the globe.
Moving on to the market and product updates. First, we'll discuss recent Medicaid activity. During the year, we maintained our industry-leading Medicaid RFP win rate of 80% with success across new contracts as well as renewals and contract expansions. Medicaid membership grew approximately 3% to year-over-year to 8.6 million recipients.
Texas, in November, Centene successfully reprocured the expanded -- and expanded its STAR+PLUS contract in Texas. We will be providing healthcare services to recipients in two new services; El Paso and Travis, while continuing to operate in our seven existing service areas. Centene currently serves 140,000 beneficiaries under our existing contracts. The new expanded contract is scheduled to commence September 1st of 2020. On a separate note, the State of Texas has now indicated that the STAR/CHIP reprocurement announcement will be sometime in February. We remain confident in the value we bring to the state.
Pennsylvania, on January 1, 2020, Centene successfully launched the third and final phase of the Pennsylvania long-term care contract, adding approximately 38,000 beneficiaries. As a reminder, we launched the Southwest Zone in January of 2018 and the Southeast Zone in January of 2019. We are the leading long-term provider in the state, currently serving approximately 90,000 recipients. The addition of the third zone will bring our total annual revenue in Pennsylvania to over $2 billion. Centene's participation in this important program reinforces our national leadership position in long-term care.
Louisiana, I'm pleased to announce that on January 17th, 2020, the Louisiana procurement officer found the state's procurement to be the most -- for the most recent RFP that I quote was fairly broad. After months of reviewing our protest, the procurement officer agreed the state failed to comply with the requirements set forth in the RFP MLR. Consequently, the procurement was rescinded and the awards were canceled. The state and awardees have appealed the decision to the Commissioner of Administration, and we are currently waiting for a resolution. We remain confident that Commissioner will uphold the procurement officer's decision. Centene's plan continues to operate under the previously mentioned emergency contract with the state.
North Carolina, as we have noted, Centene as a provider of that entity has been awarded three regions in North Carolina. North Carolina's Medicaid managed care program has been delayed from its previously announced February 1, 2020 start date, pending approval in the state budget. At this point, no official time line has been announced. We continue to maintain sufficient operations for all required implementation activities during this period [Phonetic]. In addition, we are defending our awards against ongoing protest and expect that we will retain all awards once the process is complete.
Illinois. In February, we commenced operations on the state's Foster Care program, serving approximately 15,000 beneficiaries. We expect additional enrollment of approximately 17,000 later this year.
Health insurance marketplaces. We remain pleased with the strength of our marketplace business, which has continued to be very popular and an attractive option for many consumers. In 2019, we retained our market-leading national position. At year-end, we served approximately 1.8 million exchange members in 20 states. This represented growth of approximately 20% year-over-year. For 2020, we expanded our footprint in 10 of our existing embedded states and 106 new towns.
Our continued focus on providing high-quality affordable healthcare led to a very successful open enrollment. In January, we had almost 2.2 million members across 20 states. This represents a year-over-year increase of approximately 200,000 beneficiaries. In addition, the key demographics of these members remains relatively consistent with prior years. The average age declined by one year to 42. Our retention rate increased 2% to 82%, and our fluctuation rate increased by 3% to 96%. We expect to have another strong year of operations in our industry-leading marketplace business.
Onto Medicare. At year-end, we served approximately 405,000 Medicare and MMP beneficiaries, a decrease of approximately 3% year-over-year. We did not achieve our growth expectations in Medicare, and overall performance has not kept pace with the rest of our products. We have been focused on addressing the underlying drivers of this underperformance. The addition of WellCare's high-performing Medicare portfolio will serve as an important catalyst to accelerate our growth and performance in this business. As I mentioned last month at an investor conference, we plan to operate our Medicare business under the WellCare brand name. Looking ahead, I'm comfortable that we will be able to reset the trajectory of this business.
A couple of quick comments. Our medical costs; they remains stable and in line with our expectations in the low single digits. On the rate outlook for 2019, our composite Medicaid rate increase was 2%. We are expecting a composite Medicaid rate increase of approximately 1.5% for 2020.
Now, let me provide commentary on healthcare legislation and regulatory environment. We believe that there is little desire in Washington D.C. to revisit comprehensive healthcare reform. However, Congress and the administration continue to explore ways to improve the healthcare delivery system. We are pleased with the end-of-year legislation, which included a provision fully eliminating the health insurer fee beginning in 2021. This tax not only increased the cost for seniors and those who purchase commercial coverage, but require states to pay hundreds of millions of dollars for tax that placed significant strength under Medicaid programs. In addition, the marketplace revisions aimed at stabilized individual market further indicate bipartisan support for exchanges.
Last week, the administration announced a block grant proposal aimed at giving states more flexibility with their expansion population. We are currently reviewing this proposal and look forward to working with the administration to help promote Medicaid fiscal integrity, while making sure the program remains available to those who need it. Centene welcomes the federal government's efforts to promote safe innovation across all programs to make coverage more affordable and sustainable. It represents another opportunity to be an innovative partner with the states, and Centene with its local approach is well-positioned to do so.
In conclusion, 2019 was another very successful year for Centene. We delivered solid financial performance and made significant progress against our strategic priorities. We look forward to 2020 and beyond with confidence as we continue to build on this positive momentum with a focus on driving significant growth across the portfolio with an enterprise on organic growth and an emphasis on organic growth. Continuing our focus on operational excellence and margin expansion and investing in the strength, scale and quality of our enterprise and portfolio to position us to continue to deliver value over the long-term.
Thank you for your interest in Centene. Jeff will now provide you with further details on fourth quarter and full year 2019 financial results. Jeff?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Thank you, Michael, and good morning. This morning, we reported strong fourth quarter and full year 2019 results. Fourth quarter revenues were $18.9 billion, an increase of 14% over the fourth quarter of 2018. And adjusted diluted earnings per share were $0.73 this quarter compared to $0.69 last year.
Now let me provide additional details for the fourth quarter. Total revenues grew by approximately $2.3 billion over the fourth quarter of 2018, primarily as a result of growth in the health insurance marketplace business, expansion in new programs in many of our states in 2019, particularly Arkansas, Illinois, Iowa, New Mexico and Pennsylvania, and our recent acquisitions in Spain, this growth was partially offset by the health insurer fee moratorium in 2019.
Moving on to HBR. Our health benefits ratio was 88.4% in the fourth quarter this year compared to 86.8% in last year's fourth quarter and 88.2% in the third quarter of 2019. The year-over-year increase was attributable to the health insurance marketplace business where margins have normalized as expected from favorable performance in 2018. The increase was also due to the health insurer fee moratorium. Sequentially, the 20-basis-point increase in HBR from the third quarter of 2019 is primarily due to the normal seasonality in the health insurance marketplace business and a moderate increase in flu-related costs.
The HBR for the fourth quarter was higher than our expectations, driven by higher-than-projected medical costs in our marketplace business and slightly higher than projected flu costs. The marketplace business continues to perform well and finished the year with pre-tax margins well within our targeted 5% to 10% range. Marketplace membership remains strong as we ended the year with approximately 1.8 million members. For 2020, we expect our peak enrollment to be approximately 2.2 million members, representing growth of over 10% from last year's peak enrollment. This is in line with the range that we provided at our December Investor Day.
Now on to SG&A. Our adjusted selling, general and administrative expense ratio was 9.5% in the fourth quarter this year compared to 9.9% last year and 8.8% in the third quarter of 2019. The year-over-year decrease reflects the leveraging of expenses over higher revenues and lower variable compensation cost in 2019. The sequential increase is primarily due to an increase in selling costs in the fourth quarter of 2019 and the impact of approximately $440 million of at-risk state directed payments in California recorded in premium revenue in the third quarter of 2019. Additionally, we spent $0.05 per diluted share on business expansion costs during the fourth quarter.
During the fourth quarter, we recorded $30 million or $0.05 per diluted share of debt extinguishment costs related to the redemption of our $1.4 billion 5.625% senior notes due February 15, 2021. This includes the call premium, the write-off of unamortized debt issuance costs and a loss on the termination of the $600 million interest rate swap associated with the notes.
Investment income was $126 million during the fourth quarter compared to $67 million last year and $98 million last quarter. The year-over-year increase reflects increased investment balances over 2018, including the proceeds of our $7 billion senior note issuance related to the planned financing for the cash consideration of the WellCare acquisition, improved performance associated with our deferred compensation portfolio and the impact of higher investment balances. Sequentially, investment income increased in the fourth quarter due to the higher investment balances associated with the WellCare financing and improved performance associated with our deferred compensation investment portfolio, which fluctuates with its underlying investments.
The earnings from our deferred compensation portfolio were substantially offset by increases in deferred compensation expense recorded in SG&A. Interest expense was $113 million for the fourth quarter 2019 compared to $98 million last year and $99 million last quarter. Both the year-over-year and sequential increase reflects a net increase in borrowings related to the issuance of an additional $7 billion in senior notes in December 9, 2019, used primarily to finance the cash consideration of the WellCare transaction.
Our effective tax rate for the fourth quarter was 22.3% compared to 32.5% in the fourth quarter of 2018. The decrease is driven by the impact of the health insurer fee moratorium. Sequentially, the fourth quarter tax rate was in line with our expectations and lower than the third quarter tax rate, driven by the vesting of our employee stock awards, which occurs every December.
Now on to the balance sheet. Cash and investments totaled $21.4 billion at quarter end, including $7.2 billion held by unregulated subsidiaries. Our risk-based capital percentage for NAIC filers continues to be in excess of 350% of the authorized control level. Debt at quarter end was $13.7 billion, which includes $93 million of borrowings on our revolving credit facility. Our debt-to-capital ratio at the year-end was 34.3%, excluding our non-recourse debt and the senior notes issued to fund the WellCare transaction. This compares to 37.4% at the fourth quarter last year and 35.6% at the third quarter of 2019.
Our medical claims liability totaled $7.5 billion at quarter end and represents 45 days in claims payable compared to 48 days in the third quarter of 2019. The decrease in DCP is driven by a reduction in state directed payments that are a component of our medical claims liability. As we have highlighted in the past, we expect the DCP to be in the mid-40 range on a run rate basis, but state directed payments at the end of some quarters have increased our DCP to a higher level. In the fourth quarter, we did not have any material state directed payments included in our medical claims liability, which drove the decrease in DCP. Historically, these payments were administered as pass-through and not a component of medical cost. But as states have moved these payments into premiums with a small amount of risk, they have been included in premium revenue and medical cost.
Cash flow used in operations was $651 million in the fourth quarter and cash flow provided by operations was $1.5 billion for the full year 2019 or 1.1 times net earnings. Operating cash flow for the fourth quarter of 2019 was negatively affected by the timing of payments from a few of our state customers as well as the absence of material state directed payments that I previously mentioned.
Now let me provide an update on the WellCare acquisition. We are pleased to close the WellCare acquisition on January 23rd and have begun the integration process. Each WellCare share was converted into 3.38 shares of Centene common stock valued at $66.76, plus $120 per share in cash for a total value of $19.6 billion, including $1.95 billion of assumed debt. Based on the closing price of Centene stock on the acquisition date, we expect our debt-to-capital ratio to be approximately 39% at close, excluding any share repurchases or repayment of debt associated with the proceeds from divestitures. Given the closing date, the results for January will be prorated for our ownership period of WellCare and the divestiture of our Illinois business.
Now shifting to 2020, as stated in our press release this morning, we will be providing consolidated guidance, including the WellCare acquisition on Tuesday, March 3rd, with a conference call the morning of March 4th at 8:30 A.M. Eastern Time. As I just highlighted, we need to close the month of January and prorate the activity for the month's performance and account for the divestiture transaction.
Absent the WellCare acquisition and related divestitures, the Centene stand-alone guidance we provided at our Investor Day in December was still intact. We remain comfortable with the previously communicated accretion targets of no less than breakeven in the first full year post-acquisition and mid to upper single-digit accretion in the second full year. Additionally, we continue to expect year two net synergies of $500 million and run rate net synergies of $700 million. We will provide an update to all these metrics on the March 4th call.
While we will provide our formal guidance in March, I would like to highlight a few headwinds and tailwinds that will affect the guidance for 2020. First, the headwinds, In the S-4 WellCare assumed the North Carolina contract would begin on February 1st. Moving the start date to October 1st in line with our model reduces revenue and earnings for 2020. Second, due to the closing date, Centene will not incorporate 22 days of WellCare's January results into the combined 2020 guidance. Additionally, the amounts in the S-4 did not account for any divestitures. The total divested business represents approximately $3.6 billion in annualized 2020 total revenue and 650,000 members.
Now turning to tailwinds, WellCare had a successful open enrollment period for both its Medicare Advantage plans and Part D plans. Medicare annual enrollment was in line with expectations, and the PDP business currently has approximately 4.4 million members. Given the timing of close, we continue to review WellCare's 2019 results, including any one-time items in the effect on the 2020 forecast. As stated earlier, we will provide a full update on the March call.
In summary, 2019 was a successful year for the company as we continue to execute on our growth strategy. We grew both total revenues and adjusted earnings by approximately 24% over 2018. Total revenues grew by $14.5 billion and adjusted diluted earnings per share by $0.88. We reduced our leverage by 300 basis points in 2019 in preparation for the WellCare acquisition and continue to expand net income margins.
Looking forward, we expect to leverage the combined capabilities to provide meaningful growth and efficiencies across all of our product lines. We are focused on executing the integration plan and achieving our stated synergy and accretion targets.
That concludes my remarks. And operator, you may now open the line for questions.
Questions and Answers:
Operator
Thank you. We will now begin the question-and-answer session. [Operator Instructions] Our first question comes from Kevin Fischbeck with Bank of America. Please go ahead.
Kevin Fischbeck -- Bank of America -- Analyst
All right. Great. Thanks. That Wellcare commentary was helpful. But I guess, I just wanted to see if there was anything else that you would highlight as far as the delay in the guidance, because I think you guys provided the guidance for Health Net before the transaction closed. So just wonder if there's anything else that kind of lowers your visibility or any other items that you really want to get color on before you provide maybe the proposed MA rates or anything like that, if you want to get a color on?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah. Just a couple of things, Kevin. I think it's just purely the timing of the closing the WellCare, or the Health Net transaction closed around the end of March and their annual 10-K audited financials were already out. And so, literally, I think, it's just the timing of close. And I think you also have the fact that their audit is not complete, as well as the last step in the regulatory approval process in this transaction was the Department of Justice piece. So, again, we were operating as two independent companies until the time of closure.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
That is a considerably larger complex number of states and businesses they're involved in. And we want to -- as you know, Kevin, we'd like to do it methodically and carefully, so taking an extra 30 days or so seemed to make sense.
Kevin Fischbeck -- Bank of America -- Analyst
Okay. And then, just -- my last question. The MLR on the exchange is coming in higher than you expect in the quarter. Can you provide a little more color as to why that was the case and why we shouldn't be worried that that's going to impact your 2020 outlook? If costs are higher, why don't you flow through into how you price for 2020 so it came in after you priced?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah, I might just start and let Jeff pick it up. We want to remind you what we have said historically. One, it is falling within our guided range of 5% to 10%. Two, we had commented how we are keeping the members longer, and so that could have an impact on the MLR in the fourth quarter. But because of [Indecipherable], the total margin impact is unaffected by it. You may want to go a little bit beyond that, Jeff?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah. I would say a couple of things, Kevin. I would say, we did see some higher non-inflation costs in the fourth quarter than we anticipated. But also a little less than half of the fourth quarter costs in the exchange business that were higher than our expectations was associated with the reconciliation of outstanding claims items that were settled and resulted in more favorable reimbursement going forward. And the majority of these were in states where we have MLR rebates. So -- and then, the other thing is, we have mentioned -- we did mention in our December Investor Day that we did expect exchange margins to continue to moderate slightly in 2020. So, I guess, what I would say is, you combine all that together, we're still comfortable with where our 2020 expectations are for the exchange business.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
It's a very strong business. And as I commented, all the demographics continues and still on the growth. And basically what people expected additional competition, etc, we continue to do well and it's -- and these one-time things Jeff talks about can have an impact. But that's -- that has a benefit going forward.
Kevin Fischbeck -- Bank of America -- Analyst
So, I guess, just to make sure, you're saying that some of these settlements were going to also prospectively impact costs upward, but there are markets where you have rebates. I guess if you had a settlement like that in Q4 and you're paying rebates why was that?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
No, no -- no, no. What I'm saying is that we had costs that we incurred in the fourth quarter that will provide better reimbursement going forward.
Kevin Fischbeck -- Bank of America -- Analyst
Better.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
And those -- yes -- and the more favorable reimbursement going forward. And those costs that we incurred in the fourth quarter happened to be in states where we have MLR rebates, so there is some mitigating effect. And it reduces those MLRs three-year rolling calculations, so it reduces the effect of the MLR going forward.
Kevin Fischbeck -- Bank of America -- Analyst
All right. Great. Thanks.
Operator
Our next question comes from Josh Raskin with Nephron Research. Please go ahead.
Josh Raskin -- Nephron Research -- Analyst
Hi. Thanks. Good morning.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Good morning.
Josh Raskin -- Nephron Research -- Analyst
Good morning, Michael. The first one, just on the difference between first year at least breakeven versus missing the first three weeks. Should we assume that that's actually a favorable thing in terms of, I think, about PDP benefit design or should we think of it as 2020 no material difference than first year post-closing?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Well, I mean that's why it's one of the reasons why we're waiting, Josh, is you have to actually close the month of January. And as you're well aware, there could be variability on the medical cost side. I think on the revenue side, you kind of know your members and you know the premium, but the cost side is what you don't know. And so, one of the reasons we're waiting until the beginning of March to give the combined guidance is just to get the actual numbers for January and do the proration math.
Josh Raskin -- Nephron Research -- Analyst
Okay. And then, how are you guys thinking about PBM opportunity on the legacy WellCare book? I don't think there was a formal announcement. I know they were talking about making some changes or at least going through the process there. Now, it's part of Centene overall, and I assume you guys will be instrumental in that decision making process. So how are you thinking about that?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah, I think -- let me -- I'll let Jeff give you the more specifics. But we said earlier that the PBM will be based in Tampa, and Jude's going to drive that process for us. And we see some real benefits in the total purchasing power to have a consolidation. You can give more specifics, Jeff. [Phonetic]
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, Josh. I think they were in process on an RFP. I think they've concluded that process. Right now, what I would say is, we're in-flight on the synergy analysis, obviously looking at their contracts and our contracts and all the PBM capabilities. And I would say, harmonizing those to achieve the value that we're trying for and the synergies. So I guess that's where we are. We've begun the process and we're in process on that now more to come in March.
Josh Raskin -- Nephron Research -- Analyst
Okay. Thanks.
Operator
Our next question comes from Ricky Goldwasser with Morgan Stanley. Please go ahead.
Ricky Goldwasser -- Morgan Stanley -- Analyst
Yeah, hi. Good morning.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Good morning.
Ricky Goldwasser -- Morgan Stanley -- Analyst
One follow-up on your answer on the PBM question. You mentioned that WellCare concluded the RFP process. Can you just clarify did they make a decision on that or do they just concluded the review of the RFP process?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
No, no. They've made a decision in that. I think they extended their contract with CBS for a period of three years.
Ricky Goldwasser -- Morgan Stanley -- Analyst
Okay. Thank you for that clarification. And then, just as we think about the MLR, obviously you talked about the moving parts in the fourth quarter that impact your initial thought. So, should we think about kind of like the flu is a 20 bps impact? Do you think it was kind of like the difference between the high end of your initial range versus where you came in? And then, when we think about the impact in the first quarter, and I know that you don't guide to the quarter, how should we think about the flu continuing to weigh on MLR?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, I guess a couple of things. I just bifurcate the marketplace versus the flu. Again, this is versus our expectations. I would say, the marketplace was two-thirds of the variance with the flu being a third. So I think that gets you close to 20 to 30 basis points on the quarter. So, I think, you're close on that. As far as the flu for Q1, we'll have to wait and see. One month is not a quarter, and so we'll have to see how flu costs pan out for the entire quarter. As you're well aware, we did talk about the effect of leap year and the additional day on the first quarter's performance, and I think we discussed that at nauseam [Phonetic] at our December Investor Day.
Operator
Our next question comes from Charles Rhyee with Cowen. Please go ahead.
Charles Rhyee -- Cowen -- Analyst
Got it. Thanks. Sorry. Maybe one more follow-up on the PBM question. If it's an extension for three years with CVS, is there any change of control provisions that would allow you as you do the analysis to consolidate the PBM operations sooner or would you have to wait for the three years to be over to really kind of roll something altogether?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
I think there is certain flexibility that built into the contract. So, obviously they knew they were in the middle of a transaction. And so, I think there's some flexibility in that. But again, we're doing the full analysis as we speak, and more to come in March.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
It's really -- and pricing with the amount of purchasing power we have will be very important.
Charles Rhyee -- Cowen -- Analyst
Understood. Thank you. And then, just going back to individual a little bit. I think you said that for the year, you're sort of well within the target range of 5% to 10%. But when we think about margin normalization over the near and medium-term, where do you think we are in the process? Do you think we're going to -- where do you think we kind of stabilize out over the next year or two? Thank you.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, I'll kind of go back to our -- what we said at our December Investor Day. A couple of things to just highlight, remember, we've always talked about 2018 was a very good year for the marketplace business. And what we saw in '19 is a margin -- a pre-tax margin that was very consistent with 2017, '16, '15. So we have seen very consistent margins since the inception of the exchange business.
For us, the outlier is really 2018, which had an exceptional year. And so, as we close 2019, I would say, margins were exactly -- they're roughly in line with that experience, meaning consistent with '17 and '16. So, we're still comfortable that in the 5% to 10% range. And I think we mentioned at our Investor Day that we saw them moderating slightly, but it's not substantial. We don't see a material moderation of margin from '19 to '20.
Charles Rhyee -- Cowen -- Analyst
Great. Thank you.
Operator
Our next question comes from Sarah James with Piper Sandler. Please go ahead.
Sarah James -- Piper Sandler -- Analyst
Thank you. So, 2020 is probably expected to be a more competitive year for exchanges. And I'm wondering if you can tell us, if you've noticed any difference on the impact that it's having on market share ramp in new markets compared to expansions in past years?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
I think, I heard the same thing last year. And we grew 10% in a market that shrank 1%. And I think we have strong networks. We saw a -- we saw the continuity of our members increase by 2%. We saw the effectuation increase. So -- at every level, and I said all last year that we know how to be competitive. It makes us better. And I think there is -- the product is strong. And our consumers recognize it right the networks we have, and we expect to be more than competitive ongoing.
Sarah James -- Piper Sandler -- Analyst
Got it. And maybe you could talk a little bit about the boost that ascension and some of the JVs could give to Medicare growth? So, should we think about that as potentially providing an opportunity to grow above-market rates for Medicare?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
No. I think we're still working through. And now that we're able to work with Wellcare and as I said we're going to be consolidating, and that we'll also be headquartered in Tampa, we might pull in. And so, we're working through that. They're working with us on the joint ventures. Those are things that are unfolding very nicely. They will take time. And I think the time to talk about the impacts they'll have will probably be when we give guidance for 2021. And the team has had the full look at it, but we really see our trajectory changing with the input of the marketing and other capabilities that Wellcare has demonstrated.
Sarah James -- Piper Sandler -- Analyst
Thank you.
Operator
Our next question comes from Steve Tanal with Goldman Sachs. Please go ahead.
Stephen Tanal -- Goldman Sachs -- Analyst
Good morning, guys.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Good morning.
Stephen Tanal -- Goldman Sachs -- Analyst
I guess, one of the RxAdvance and WellCare, sort of curious did Wellcare have full visibility into the cost and benefits of RxAdvance before renewing with CVS? And what's your view as...
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Well, we were -- I want to be very clear. We were very careful prior to the approval from Department of Justice to operate as two very separate companies. And we had no insight into their contracts, and we [Indecipherable] because the rules of that are very clear and it's the old story, you not only have to be honest, you have to be honest. And so, we -- they had no insight into it.
Stephen Tanal -- Goldman Sachs -- Analyst
Got it. Okay. That's helpful. And maybe just one other on Centene Forward, wanted to understand how you guys are sort of thinking about in the context of earnings. Did you expect at any point to sort of commit to a certain net number contribution, and is that not '20 or '21, like just any color on that?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah, let me start. I think as we said from the beginning, we are really self-funding a lot of development in our systems and systems capability. And the name of the game going forward is that -- and that's where our scale and size is $100 billion company is so important. We have -- it gives us the resources to continue to focus on the systems that's going to deliver the kind of performance, margin improvement, etc in '21, '22 and going forward. And as we start to let some of that fall in the bottom line as such, Jeff will be in a position to disclose that in a succinct way. But it's [Indecipherable] you have to -- that cost a little bit like continue to -- you have to continually trim them. And we see this as incorporated in the company. And it's a continuous process of reducing costs while improving the capabilities of the company.
And we couldn't more pleased with the $500 million that we were able to achieve this past year. And we see it continuing to grow an additional funding this year, which will just continue the next-generation of systems work. And in fact, I'm going to give just a little more color that we have -- we were really bifurcating, or trifurcating, I guess, would be the word, our systems. We have that -- we have a group that's going to be maintaining the systems that work day in and day out. We have a group that's going to be working on the transition because there's a lot of transition with these systems, and I make no secret and they don't either that WellCare knew they were going to be sold at some point. And so there's a lot of little systems that's going to take some time to transition.
And that's why we've said, it's a two, three-year process to do it right and get it right, and we're focused on that. And the third group are the advanced technology group. And these are the think-tank people, the people that have brought us things like Interpreta and others that give us real-time status for the physicians. They're going to take us to the next-generation. So that's being funded by these savings.
Stephen Tanal -- Goldman Sachs -- Analyst
Helpful. Thank you.
Operator
Our next question comes from Justin Lake with Wolfe Research. Please go ahead
Justin Lake -- Wolfe Research -- Analyst
Thanks. Good morning.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Good morning.
Justin Lake -- Wolfe Research -- Analyst
First, I just want to follow-up, one last question on the PBM. There were some talk by WellCare Group getting better economics potentially pulled forward into 2020 debt renewal, even though the contract doesn't begin or doesn't end to the end of the year, the original contract. So I'm curious, is that something we should consider that maybe 2020 could be -- could have better PBM costs rather than 2021? And then, can you tell us if the strategy is to move Medicaid over to RxAdvance from WellCare Group early and then leave the Medicare PBM for CBS during the contract?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, Justin, Jeff here. So, as I mentioned before, I mean, we're going through the process right now comparing the PBM contracts and all the capabilities that both companies have and rationalizing that for the synergy opportunity. And so, I'm not going to comment today. I kicked that question to March when we provide full combined guidance, because then we'll have the opportunity to have the benefit of visibility on both those contracts.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah. And Justin, if I may. Just -- if we think about, when you're combining these two companies, we had multiple work streams that were developed during the period of time we're waiting for Justice approval, and that's whether, its systems, and it's combining them. When you take the Florida and Georgia, they're large companies, both sides combining them.
And the things that we're doing there, and while we have divested some plants, we have obligations there to ensure a smooth transition of that membership. You put all that together, it's very complex. So, we're just trying to take a -- use the next few days to take a very careful view of it and get it right. We're not trying to duck anything, except, say, it just takes time when it's as complex as this one. I keep telling people, it's not how fast, it's how well you do it.
Justin Lake -- Wolfe Research -- Analyst
Totally makes sense. I appreciate that. And then, just my follow-up is on the exchange medical costs in the fourth quarter. So, Jeff, if we think about the -- you were above the high end of your range by about 20 basis points on MLR, so 80 basis points for the quarter. Can you give us some delineation in terms of how much of that was the exchange miss? Was it 50 or 60 out of the 80 basis points? Just trying to understand where exchange margins were in the quarter?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, yeah. I'll kind of package everything that I've said together in one, maybe this will clarify everything. So, you're right on the 80 bps. So, MLR for the quarter was higher than our expectations by 80 basis points. I said two-thirds of that was marketplace, one-third, I would say, is flu. And those are just rough right? That's -- and then, of the marketplace piece, I said a little bit less than half was associated with these reconciliation of the outstanding claims where we effectively had medical cost in the fourth quarter that will provide a benefit going forward, right. And some of that was in states where we had MLR rebates. And so, there's an offsetting effect there, but it's not a one to one because the MLR calculation is a three-year rolling calculation.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
I want to restate it. Just if I may, my simple non-financial. Okay. In fact, when you look at what we did there, we had some states where balanced going things with issues because we didn't have a contract with the hospital. We now have contracts with them. And we got those things settled, we got it right with them so we had the expense to settle those claims with those loops, but now going forward and these are larger states.
Going forward in 2020, we're going to be in a stronger position because they're now part of the network. And those kind of issues won't be there. So it was really a one-time, get it right, and it could happen again just to be very candid. But I always view those things as that's where the long-term comes in. We were in this and we continue to do very well in a long time. It will cost us a couple of bps here or there in the quarter. I'm looking at 2020, and I'm really pleased with what we see happening, particularly when I see the membership, the effectuation rate, the demographics, it's just a really great business for us.
Justin Lake -- Wolfe Research -- Analyst
Got it. Thanks.
Operator
Our next question comes from A.J. Rice with Credit Suisse. Please go ahead.
A.J. Rice -- Credit Suisse -- Analyst
Hi, everybody. Just on-- first, the comment about Medicaid rates. I think you came in, if I've got my notes right, into 2019 looking for a 1.5% increase. And I guess, today you're saying that you ended up with about a 2% all-in increase. And I'm just wondering, is that mostly due to some true-ups around the research verifications or is it something else? And were there any reverifications of note in the fourth quarter? And you're saying 1.5% for 2020, are there potential reverifications that can help you in the early part of 2020?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Well, I think -- we said, the reveri -- it's really moderating. And yes, we've had great success because of the real-time systems we've had in getting the states to recognize the membership mix and the acuity mix within it. We're never satisfied with the timing of how fast they make those investments, but part of it is, well, they say we have real-time systems, they have to wait and see what some others are doing that don't have that real-time capability, and that can slow down the whole process. So, on balance, we were comfortable that the stage in the large states we're working with, we're going to get it right with us. And it's just a matter of timing. So, which quarter it fall was in, that's a little more hard -- that's a little harder to forecast, but it's all coming together right there too.
Jeff, anything you want to add?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
No, I think Michael is exactly right. It's a timing perspective. We're not -- there are some states that were still searching for rate adjustments heading into 2020. So, again, it's a timing issue, and we're still looking for additional rate adjustments in certain states for this effect.
A.J. Rice -- Credit Suisse -- Analyst
Okay. But maybe, my other follow-up question would be, once you complete the WellCare deal, you said your pro forma, I think, debt to total cap would be at 39% as sort of your -- where that's within your target range, I believe. So, do you need some time to digest Wellcare or are you back on the acquisition hunt if something comes available that's attractive to you?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Let me comment. One, the 39%, we still determine the proceeds of sale, and we're looking at both stock buyback and retirement of debt. So that will help. But I guess, I have to respond to this and say, we're not going to look at anything serious in large. And so, we're really comfortable that the trade this transaction and the integration has taken place to a level that's appropriate. But those people that know us know that we have an insatiable appetite. And so, I would say, as soon as -- they also know we're balance sheet managers, and we look very carefully at that. So, I would say, as our balance sheet continues to strengthen, this gets integrated. And if we see opportunities, we'll be back out there.
But I have to emphasize what we said at our Investor Day, and I say it every chance, we are very driven by organic growth. And I remind people we had almost $7 billion of organic growth last year. So we're going to continue to focus on that and that's our primary focus. And then, as we see new capabilities and things we can add, we'll go in the M&A book.
Does that help you?
A.J. Rice -- Credit Suisse -- Analyst
Yeah, that's helpful. Thanks a lot.
Operator
Our next question comes from Steve Valiquette with Barclays. Please go ahead.
Andrew Mok -- Barclays -- Analyst
Hi, good morning. This is Andrew Mok on for Steve. Just wanted to follow-up on the MLR and exchange commentary. It sounds like you're attributing most of the MLR pressure to the exchange business. If we look back at full year 2019, how did Medicaid MLR perform relative to your expectations?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Medicaid in aggregate, I think Medicaid was within the range. It wasn't -- we would have called it out if it was a material one way or the other on the full year, when you look at year-over-year results.
Andrew Mok -- Barclays -- Analyst
And then, one clarification related to divestitures. You noted that the S-4 did not include divested business. That comment was referring purely to revenue, correct? Your deal -- your net deal synergies have always reflected synergies, correct?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Just specifically on the revenue line.
Andrew Mok -- Barclays -- Analyst
Okay, great. Thanks.
Operator
Our next question comes from Scott Fidel with Stephens. Please go ahead.
Scott Fidel -- Stephens, Inc. -- Analyst
Hi. First question just on the new block grant proposal. I appreciate that you're still digesting that. And Michael, I know you gave some initial comments. Just interested -- just that this sort of initial sort of stance here. How are you thinking about this in terms of this being more of a net sort of positive around the innovation opportunity that you mentioned or more of a net potential negative around the funding caps and potential risk to rates or do you think that there's simply going to be some different moving pieces headwinds and tailwinds to this?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Let me -- I don't want to be very general on it because it's so early in it. But as we said, this is -- this involves expansion, not the current businesses is key and focused on the expansion of the area. Caps -- block plans work really well in states that are not growing -- and state of Oregon, it can have an impact, so various states will have various impacts.
But as we look at it, we think -- I'm going to say that I tilt toward a net positive on it because it's giving the states some opportunities to be innovative. And as you know, we are very decentralized and our local plans have strong relationships with those states. And I think they'll be in a position to be able to help the states with that and use some of our assistance capabilities and tests and model things, but it is limited to the expansion aspect of the business. So that's key. So I think going forward, I'm going to tilt to the positive side, but we're going to continue to work with it and help to make it better.
Scott Fidel -- Stephens, Inc. -- Analyst
Okay. And then, for my follow-up question, I know there are bunch of different MLR dynamics discussed in the exchanges. Jeff, just interested in sort of where the thinking is right now on the risk adjuster payable, ending the year really two things in particular I just wanted to ask about one? One of -- one of your peers had cited the weekly report that came out at the end of the year, and that had led them to make some adjustments to their risk adjuster assumptions.
And then also just interested just in terms of those higher 4Q costs that you had in the exchange business, does any of that sort of flow through to the estimated acuity profile of your population relative to the market or were those just sort of other factors that don't play into the risk adjuster assumptions? Thanks.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, a couple of things. I guess, our risk adjustment was in line with our expectations. And when the 10-K comes out, you'll see the total number. We've got roughly $1 billion of payable to the government on the books. So, it wasn't -- it's really a risk adjuster phenomenon for us. It was really just higher non-inpatient costs. And as you're aware, we have to get those -- we're estimating a significant portion of our medical costs. And so, we'll have to wait for those claims to come in and look at the diagnosis codes and submit those for risk adjustment. And so, there may be an effect there, but it's too early to tell.
Scott Fidel -- Stephens, Inc. -- Analyst
Okay. Thank you.
Operator
Our next question comes from Lance Wilkes with Bernstein. Please go ahead.
Lance Wilkes -- Sanford C. Bernstein -- Analyst
Yeah. A question on how you're going to manage the company going forward. And I was interested in both what's the org structure you've got in place right now as far as, Michael, to you the direct reports? And then, as you think of management process, what's the process you've got in place now for legacy Centene, legacy WellCare, and integration? And how do those differ?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah. I think, let me -- from a management perspective, we laid out at our June Investor Day, the organization chart that we were working with us initially. And Drew is going to report to me to become part of my senior management team because of the increased focus on pharmacy at this point in time.
Ken, in fact he should be here later today in his new role of markets and products he'll help me to do that and bring that in place. But that's all been laid out. And we operate in what I call a partnership. And people have clear responsibility, accountability, the responsibility and the authority to manage their businesses.
When you add a scale, we are -- this enterprise is now international in scope, you have to do that. So it's very -- the accountability is just -- is very, very clear. So, going forward, that's the basis on which we're doing it. In terms of the integration, as you raise it, there's different work streams. The systems, and I've commented on that, that's going to take time. And there's a group working on the transition of systems. WellCare is in the middle of transitioning some of their systems. We're bidding in another. So that all has to be brought into play. The general ledge, I think, Jeff explained to be on a general ledger by July 1. So that will all be in place, and that's in place. They will be moving to our form of -- we've reserved calculations as that occurs and we're doing some of that now. We use date receipt. So all those things is different work streams for it, it's coming together.
We know who will be managing what markets and they control that, and that's moving through. And it's because of the need for systems that we're going -- it's going to take a little bit of time. You take Florida, they had a large business, we have a large business. And so, we're going to operate there in two systems for a short period of time till we can convert to our system.
So this has all been laid out and it's very detailed, and it's something that the Board looks at every quarter. We've probably spent 30, 40 minutes reviewing where we are and how it's going at our Board meeting yesterday. So it's something we're very comfortable with. And I remind people, it's something we've done historically.
I mean, Fidelis was a large company last year, and it's fully integrated, simply moving the claims to our platform, which we said all along would take some time. Health Net was integrated. So, I mean, this -- and the fact that we have strong management in both companies. Now, I just want to add one more thing that we just lay out to everybody, so they know it that we had culture surveys of their culture and our culture. And we can say, this is yours, this is ours. And ours is the one will prevail. We're not trying to blend things and we have found historically that makes a difference.
We also said right upfront that all things being equal in terms of performance, the Centene person gets a job it's as two people for the same job. That does not mean that the WellCare person will not be repurposed into a very senior that gives them challenging new opportunities, but it also gives them comfort that the next time we do a deal that they have that same protection. So these are things that we have historically done that worked really well for us and helped to ensure a smooth transition, and we expect that again. Does that help you?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah. Yeah, it does. And just as a follow-up, as you spoke about, maybe not doing large-scale M&A right now until this is digested, but obviously having an ongoing appetite for M&A in general. Could you talk a little bit about the priorities and talk to whether there are regions or particular capabilities in light of having the combination of both companies?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Okay. Well, I think, it's going to -- once again, it's -- we talk about capabilities. Some of that may be systems. And there are some smaller acquisitions we can make, because of our size of scale, we don't have to disclose it. I have jokingly told people that we did one deal and the person, we say, we don't have to disclose him, because he said, now my family's not going to be chasing me for some of this money. So, I mean, there's some benefit there, but we do that type of thing.
Two is the capability to see if some other opportunities come up nationally and internationally, we'll do it. But when I say scale and size, when you're now a $100 billion plus enterprise, with $5 billion of EBITDA to bottom and the balance sheet that we have and the improved credit rating that we have. And what we're able to sell our bonds at and what our bonds are trading at it says that what's relative and what can be done has changed a little bit from several years ago. But we will once again just focus on what's the strategic value, and it has to make financial sense first then strategic value, and then we'll look at the capabilities it brings. And I can't go beyond that, because then I'd be starting to tell you who we're looking at.
Lance Wilkes -- Sanford C. Bernstein -- Analyst
Okay. Thanks a lot.
Operator
Our next question comes from Peter Costa with Wells Fargo Securities. Please go ahead.
Peter Costa -- Wells Fargo Securities -- Analyst
Thanks for squeezing me in here. Just want to belabor the point on the MLR guidance for the HICS business one more time just to ensure I fully understand what you're saying. You've talked about being in the range of 5% to 10%. But you've trimmed back that guidance into that range a couple of times now, so it seems like you're probably in the mid to the lower half of that range. You talked about for next year still some non-material moderation of that. So does that really imply that next year you're going to be in the lower half of that range that you've talked about for sure? Presumably the tailwind that you picked up from the risk adjusters being a little better as of the fourth quarter reconciliations doesn't help you that much? And then finally, does this have anything to do with the Iowa Medicaid claim payments that you were delayed?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
The Iowa we all know had some issues. We were comparable. And so, as soon as it got our attention, it's being fixed. And we made all the progress you made and that's kind of historic. And it's not material we're going to get the funding. Is that a question there?
On the medical losses, I want to remind you that it will vary from quarter-to-quarter based on out-of-pockets max and out-of-pockets a lot of different things. So what we're saying is that in any given quarter, you'll see some variation. Now we also know that the last quarter, the year tends to be higher because the maximum out-of-pockets have been met and sometimes people try to get some services and other things done. And Jeff commented that the inpatient was a little bit higher, but I expect some of that on balance, the 5% to 10% is a solid range. We're very comfortable with it.
And in the first quarter, it's going to be in the higher part of that range. In the last quarter, it could be in the lower part of that range but on balance. And we tend to -- we love to be conservative. We love to under-promise and over-deliver where we can. And so we're saying, it's realistic to say that as the business grows, there may be a little moderation, but it's still solid and it's solidly in the 5% to 10% range. But if I tell you where then I'm giving you more than we have historically -- it serves no purpose. It's great business.
Peter Costa -- Wells Fargo Securities -- Analyst
Thank you.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Thank you.
Operator
Our next question comes from Matthew Borsch with BMO Capital Markets. Please go ahead.
Matthew Borsch -- BMO Capital Markets -- Analyst
Thank you for squeezing me in. Just a quick question about the group commercial business, I know it hasn't been front and center for a while, and I'm curious what your thoughts are on the state of that business as you come into 2020, the intensity of competition there?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah, we have some of it in California. We've said we'll maintain it. It's good business for us. And I would say that all that's under a strategic review.
Matthew Borsch -- BMO Capital Markets -- Analyst
Okay.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
But honestly Matt, I'm back burning a little bit, so I want to get -- I want to get WellCare fully integrated and get things before we start distracting people and some other opportunities.
Matthew Borsch -- BMO Capital Markets -- Analyst
All right. All right. Thank you.
Operator
Our next question comes from Michael Newshel with Evercore ISI. Please go ahead.
Michael Newshel -- Evercore ISI -- Analyst
Thanks. Maybe just going back to the divestitures. Thanks for the revenue number, but can you also make any comments relative to profitability and size of the proceeds? And have you actually decided whether you're going to redeploy on buybacks or debt paydown or is that still to be determined as you put the consolidated guidance together?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yeah, we were going through right now that analysis. And that's going to be a function of stock price as much as anything. And so, stay tuned, that's something will resolve probably Jeff what the next 30 days or so?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah. Yeah, absolutely. And then, the other thing on the size of proceeds, $1 billion pre-tax. So $1 billion pre-tax is the proceeds. And that -- by the way that also includes statutory capital as well.
Michael Newshel -- Evercore ISI -- Analyst
Yeah. Got it.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
I think it was a fair transaction for everybody.
Michael Newshel -- Evercore ISI -- Analyst
Maybe one more just sorry if I missed it. But do you have any update to marketplace enrollment expectations for 2020 now that open enrollment is over?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yes we said 2.2 million -- 2.2 million members peak.
Michael Newshel -- Evercore ISI -- Analyst
Got it. Thanks.
Operator
Our next question comes from Ralph Giacobbe with Citi. Please go ahead.
Ralph Giacobbe -- Citigroup -- Analyst
Thanks. Good morning. First just a quick clarification. Did you say the higher MLR was it non-inpatient? I think Jeff that's what you said. I thought Michael you said non-inpatient?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Yes, non-inpatient.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
It was non-inpatient side, sorry.
Ralph Giacobbe -- Citigroup -- Analyst
And then if you could just flush out when you say non-inpatient is that just elective outpatient? Is it drug? Just help us in terms of what areas popped to that magnitude to drive the MLR?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
I think we just saw normal PCP visits. So it wasn't necessarily in the specialist category. So just higher doctor visits is what I would say.
Ralph Giacobbe -- Citigroup -- Analyst
Okay. All right. Fair enough. And then, just my quick follow-up here. Any initial comments around some of the proposed changes for HIFs in 2021? And I guess, specifically around pulling tax credits for those who pay zero premiums [Technical Issues] and don't update their income. I guess, just trying to understand logistically, do most update each year? So it's a non-issue? Or how easy would it be for you all to sort of aim and making sure this sort of gets done? And if you could, just what percentage of your HICS enrollees pay zero premium? Thanks.
Kevin Counihan -- Senior Vice President, Products
Hi. This is -- it's Kevin Counihan. So, the payment notice just came out Friday as you know. We're still digesting a lot of those issues that you speak to. We've got broad diversity of folks within the FPL range. I think, as you know, though we tend to have the majority under 250, so again not trying to be evasive, but we still are just working through the payment notice.
Ralph Giacobbe -- Citigroup -- Analyst
Okay. Fair enough. Thank you.
Operator
Our next question comes from Dave Windley with Jefferies. Please go ahead.
Dave Windley -- Jefferies -- Analyst
Thanks. Thanks for squeezing me in. So, I wanted to ask a question on revenue, may seem trivial but you were outside of your revenue range by about $400 million. It doesn't seem like exchange retention is enough to account for all of that. I just want to make sure they weren't any one-time benefits flowing through the revenue line?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
No. I think -- Dave, I think, we mentioned in the, I guess, in our December Investor Day that we thought of the Q3 call or December Investor Day that our fourth quarter revenue would be lower than our third because of the size of the pass through payments. And I think we did get a few pass-through payments in the quarter that kind of helped revenue. We don't have great visibility on these -- from states. And so they just show up. So I think our -- we expected a bigger drop in revenue from Q3 to Q4, but we had $100 million or so in payments.
Dave Windley -- Jefferies -- Analyst
Okay. And then, second question, just again to go back to your headwind and tailwind commentary. I want to make sure I understand that that is relative to S-4, but that your guidance both on -- to the earlier question about divestitures, but also in terms of timing of close that it would seem that those two items relative to what you would have baked into your neutral in year one and mid to high single digit accretion in year two, that particularly the year one element of that, that those two things probably came out better than we expected. Timing of close and the magnitude of divestitures?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah, yeah, but the timing of close. I mean, when we gave our numbers we are -- the accretion target is a full year, right? So it doesn't really matter when it starts, it's a full year. And my point on the guidance is that, we're going to have to prorate January, and that's going to have an effect, right? I mean, if you just take the WellCare topline number that they were expected to hit for 2019 and you take 22 days out of that, that's a sizable number.
Dave Windley -- Jefferies -- Analyst
Okay. Fair enough.
Operator
Our next question comes from Gary Taylor with JPMorgan. Please go ahead.
Gary Taylor -- JPMorgan -- Analyst
Hey, good morning.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Good morning, Gary.
Gary Taylor -- JPMorgan -- Analyst
Hi. I wanted to -- I had a clarification on that last point as well. So maybe I'll try to put it a little clear because I've had a few questions. So, Jeff, when you've had laid out some of the headwinds around WellCare, those are relative to ultimately the 2020 consolidated proforma guidance you're going to give, those are not headwinds to the year one at least neutral accretion guidance?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yes, yes -- yeah, that is correct. Yeah, yeah, you're correct on that.
Gary Taylor -- JPMorgan -- Analyst
Okay. I just had a couple of questions. My last one, I wanted to go back to the exchange question, just one more time and make sure I understood about -- you had mentioned that some of the increased costs were in states where you were already up against the minimum MLRs that had some accruals. So, effectively costs -- additional costs you would have incurred in those states, I guess, might have -- would not have impacted earnings because you'd already -- your margin is essentially already capped -- your MLR is already capped. And then, consequently, moving into next year any improvement wouldn't flow through the earnings? Because again, your MLR at least is already essentially capped, if you're into the minimum MLRs. Am I understanding that correctly or is there a different point you were trying to convey on that part?
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
The biggest piece of that that you're missing is that, the MLR calculation is a three-year rolling calculation.
Gary Taylor -- JPMorgan -- Analyst
Right.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
So to the extent we had costs in the fourth quarter, and you're in a minimum MLR rebate, it's not a 1:1, right? And it depends on the magnitude of the prior year MLR rebates. And so, when you go forward, if I had lower MLR rebate in 2019, that is a lower amount that I have to deal with in the future, right? So it's not a 1:1. I mean, you could -- if everything was equal per year, you could say it's a one-third benefit. So if we had costs in the fourth quarter, we'd get a-third of that back. But the math isn't that simple, because every year is a different MLR number.
Gary Taylor -- JPMorgan -- Analyst
So the math is complex, but I think the point you were trying to convey though, at least, was that the thought that in incurring some of these settlements and reaching in network agreements with some of these PCPs ultimately was going to provide some better MLR performance in 2020. Is that fair?
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yeah. Well, I would say, there's two things. Number one, it's better reimbursement, more favorable reimbursement for us going forward as a contracted provider, right? So that helps. And then, yes, it reduces the aggregate level of MLR payable that you have and so, thereby provides a benefit going forward.
Gary Taylor -- JPMorgan -- Analyst
Okay. Thank you very much.
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Yes.
Operator
Our next question comes from George Hill with Deutsche Bank. Please go ahead.
George Hill -- Deutsche Bank -- Analyst
Hey. Good morning, guys, and thanks for squeezing me in. A lot of my questions have been answered. I guess, I'd ask one kind of philosophically on the Medicaid demonstration projects around the block grants. Do you guys in the pharmacy business feel like you're better off with the statutory rebate on the drug side or do you feel these guys feel like the business would be better served taking a formulary approach in being able to negotiate your own discounts and rebates? Thanks.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Well, I mean, I always -- I've always liked the idea, we are more masters of our destiny, right? But, I think, when you have the systems we have and the capabilities where we're going, we have the flexibility to work either way. So, we -- we'll make our decisions, as I've always said, based on the facts of what they are at the time. And these are still issues under discussion. And there's opportunities to influence some aspects of that, we believe. And that's what we'll do. And it's -- we just take a very open-ended approach to it. And I'm comfortable we'll end up in a strong position at the end of the day.
George Hill -- Deutsche Bank -- Analyst
Thanks. I appreciate the color.
Operator
This concludes our question-and-answer session. I would like to turn the conference back over to Michael Neidorff for any closing remarks.
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Well, we thank you for your comments and thoughts today and the chance to clarify some of these things. And we're looking forward to the March 4th, as I recall, that's the date, Jeff, where we're going to be able to give you the full guidance and kind of set the baseline on what this combined company will be doing going forward. We believe it will be very significant. So, thank you and we'll be talking to you again in March.
Operator
[Operator Closing Remarks]
Duration: 78 minutes
Call participants:
Edmund Kroll -- Senior Vice President, Finance and Investor Relations
Michael F. Neidorff -- Chairman, President and Chief Executive Officer
Jeffrey Schwaneke -- Executive Vice President and Chief Financial Officer
Kevin Counihan -- Senior Vice President, Products
Kevin Fischbeck -- Bank of America -- Analyst
Josh Raskin -- Nephron Research -- Analyst
Ricky Goldwasser -- Morgan Stanley -- Analyst
Charles Rhyee -- Cowen -- Analyst
Sarah James -- Piper Sandler -- Analyst
Stephen Tanal -- Goldman Sachs -- Analyst
Justin Lake -- Wolfe Research -- Analyst
A.J. Rice -- Credit Suisse -- Analyst
Andrew Mok -- Barclays -- Analyst
Scott Fidel -- Stephens, Inc. -- Analyst
Lance Wilkes -- Sanford C. Bernstein -- Analyst
Peter Costa -- Wells Fargo Securities -- Analyst
Matthew Borsch -- BMO Capital Markets -- Analyst
Michael Newshel -- Evercore ISI -- Analyst
Ralph Giacobbe -- Citigroup -- Analyst
Dave Windley -- Jefferies -- Analyst
Gary Taylor -- JPMorgan -- Analyst
George Hill -- Deutsche Bank -- Analyst
