Sarah James; Analyst; Cantor Fitzgerald & Co.
Andrew Mok; Analyst; Barclays Capital Inc.
Lance Wilkes; Analyst; Sanford C. Bernstein & Co.
Adam Ron; Analyst; BofA Securities, Inc.
Scott Fidel; Analyst; Stephens Inc.
Michael Ha; Analyst; Robert W. Baird & Co. Incorporated
Dave Windley; Analyst; Jefferies & Company, Inc.
Good day, and welcome to the Centene Corporation third-quarter results conference call. (Operator Instructions) Please note, this event is being recorded.
I would now like to turn the conference over to Jennifer Gilligan, Head of Investor Relations. Please go ahead, ma'am.
Thank you, Rocco, and good morning, everyone. Thank you for joining us on our third quarter 2024 earnings results conference call. Sarah London, Chief Executive Officer; and Drew Asher, Executive Vice President and Chief Financial Officer of Centene, will host this morning's call, which also can be accessed through our website at centene.com. Ken Fasola, Centene's President, will also be available as a participant during Q&A.
Any remarks that Centene may make about future expectations, plans and prospects constitute forward-looking statements for the purpose of the Safe Harbor provision 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 third quarter 2024 press release, which is available on the company's website under the Investors section.
Centene anticipates that subsequent events and developments may 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.
We 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 third quarter 2024 press release. Please mark your calendars for our upcoming Investor Day being held on December 12 in New York City.
With that, I would like to turn the call over to our CEO, Sarah London. Sarah?
Thank you, Jen, and thanks, everyone, for joining us as we review our third quarter 2024 financial results.
Given the recent market volatility impacting managed care, let's start with the bottom line upfront. The overall outlook for our business remains consistent with our updates in the quarter. We remain confident in our full year 2024 adjusted diluted EPS guidance of greater than $6.80, and our view of headwinds and tailwinds as we look to 2025 are largely unchanged from what we have previously shared.
We still believe that we will grow adjusted EPS next year, and we still believe that we have a unique and powerful platform from which to drive long-term EPS growth of 12% to 15% in a normalized environment.
Specific to the quarter, we are reporting third quarter adjusted diluted EPS of $1.62, a stronger result than our most recent expectation for the period, with the upside driven in part by anticipated tax items shifting forward into the third quarter.
Within our core business lines, Medicare and Marketplace performance was consistent with expectations in the quarter, and Medicaid performance ended up a little better than our mid-quarter commentary, aided by movement in rates we saw as a result of refreshed data and effective advocacy.
In general, we are encouraged by progress we saw throughout the quarter relative to our ongoing dialogue with state partners to align Medicaid rates with the acuity of our post redeterminations book of business. We have spent the better part of 2024, offering a significant level of transparency into our business during a year of unprecedented change. We are pleased that this transparency positions us today with a stable outlook for 2024.
With that, let's get into the details, starting with Medicaid. As you know, our largest business has undergone significant transformation over the last 18 months as a result of the nationwide return of eligibility determinations. Since the start of this process, millions of Americans have been transitioned out of managed Medicaid across the country, materially shifting the Medicaid risk pool in a way that requires action by our state partners to rightsize program rates to reflect the post redeterminations member base.
During the third quarter, our state partners continued to work through the tail of their respective redetermination processes. And as we sit here today, the vast majority of the 30 states in which we operate are now through their respective backlogs. We closed the period with roughly 13 million members and are seeing evidence of membership leveling as we move into the fourth quarter.
Since this process began, you have heard a consistent message from us in terms of our boots-on-the-ground support for our members and, equally, our proactive data-driven dialogue with our state partners to ensure rate discussions throughout this period are fully informed and benefit from the most current data. As we sit here today, all of our states have acknowledged the need to match rates with acuity, and all of our states have now taken action with respect to acuity adjustments in some form.
While there is still work to do with respect to the sufficiency of rate adjustments, our conversations continue to be productive, and we are encouraged by the engagement and the incremental movement we saw as the quarter unfolded. We now expect our back half composite adjustment rate to be in the 4.5% to 5% range. As state-by-state experience matures, we are still seeing just over 30% of members who were initially dropped from Medicaid eligibility ultimately returned to us.
Less than half these rejoiners are reinstated with retroactive coverage. The majority experienced a coverage gap, which means we experience a corresponding premium gap. As we have discussed previously, this creates temporary pressure on the Medicaid MLR.
However, a close look at the rejoiner trend suggests that is starting to slow. This incremental lessening of pressure as we move through Q4 and evidence of a return to a more normal churn rate across the Medicaid book offers a natural tailwind as we move into 2025.
We continue to track the data closely and provide regular and detailed updates to our state counterparts. We believe the solid foundation of data-driven advocacy we have built over the last six quarters has served us well and will continue to do so as we advocate for appropriate 2025 rates and mid-cycle acuity adjustments.
Overall, the movement we have seen in rates over the course of 2024 reinforces our view that what we are experiencing is a temporary dynamic and that state Medicaid programs will ultimately return to actuarially sound rates that match acuity.
While redeterminations have captured much of the attention over the last few quarters, it should not go unnoticed that Centene has been equally busy delivering strong RFP results and positioning our Medicaid business for long-term growth. In August, the team at Pennsylvania Health and Wellness reprocured our long-term support services business in that state, reinforcing the strength of this organization in serving low-income members with complex support needs.
In September, we successfully reprocured our statewide presence in Iowa in a highly competitive process. And then earlier this month, Centene's Meridian Health Plan in Michigan won yet another 2024 RFP, this time providing integrated Medicare and Medicaid services for dual-eligible members as Michigan transitions their statewide program to a HIDE SNP. In short, we are making progress against rate and acuity alignment and our best-in-class business development team continues to effectively articulate our value proposition.
Throughout it all, our teams have worked tirelessly to advance our Medicaid quality results, deliver operational and compliance improvements, and innovate through local partnerships as we serve the most underserved communities across the country. And so while the redetermination process has been challenging, it is nonetheless mobilized us toward an operating discipline that is creating a stronger, healthier platform from which to grow.
Turning to the rest of the business. Our Medicare segment continued to perform in line with expectations during the quarter. As we look ahead, Medicare Advantage remains a strategically important pillar of our platform and represents significant opportunity for margin expansion as we continue to improve Stars, reduce SG&A, and advance our clinical programs.
To this end, our 2025 Star ratings released earlier this month with financial implication for 2026 represent a meaningful step forward on the journey to margin recovery.
These results demonstrate our ability to effectively identify areas of potential improvement and methodically execute on delivering those enhancements. During the cycle, we elevated our performance with 46% of members in plans at or above 3.5 stars versus 23% from the prior year despite higher-than-industry anticipated cut point changes. Our Star results represent strong overall improvement in our core operations and continued focus on quality for our members.
Consistent with what we previewed on the Q2 call, we used 2025 bids as an opportunity to further focus our franchise on lower income seniors and tighten the alignment between our Medicare Advantage business and our Medicaid footprint. We exited six states while strengthening our offerings in key counties and regions within our existing footprint.
As a planned byproduct of this work, we were able to streamline our contract portfolio creating more balanced membership across our contracts and enabling greater focus and impact in our program investments going forward.
These adjustments position us for a preliminary view of 2025 Medicare Advantage revenue in the range of $14 billion to $16 billion. As we have shared previously, this implies down membership year over year but represents progress on our path to breakeven in this business.
Within our Medicare portfolio, our Part D business will generate a more sizable revenue contribution in 2025, owing in part to significant changes adopted as a result of the Inflation Reduction Act. Though it is early, we are pleased with our preliminary view of product positioning, and we expect Part D revenue to grow significantly next year with potential for membership growth as well.
In light of recent policy changes that make Centene's industry-leading Medicaid footprint a competitive advantage as we look to serve more dual-eligible Medicare members, we remain focused on the compelling opportunity our Medicare platform provides for both margin expansion and growth long term as we turn around and stabilize this business.
Finally, our marketplace business continues to perform well in 2024. Our results in the quarter were in line with our most recent expectations as we capitalize on more than a decade of experience to effectively serve now 4.5 million members.
Looking to 2025, we believe our marketplace products are well positioned relative to our strategy. Open enrollment will not begin for another week, but our early expectation is that we will be able to achieve pretax margins well within our targeted range of 5% to 7.5%.
Centene demonstrated our thought leadership in Marketplace earlier this year by implementing an agent of record lock policy, which was subsequently implemented market-wide by CMS in July. In addition, CMS has introduced program integrity processes in line with both Centene advocacy and pre-pandemic era policy that will further improve controls on exchange enrollment during this open enrollment cycle.
These types of policies improve the member experience as well as the quality of our book, but we do expect they will create a moderating effect on overall market growth in 2025. As a result, our membership growth expectation for this year's marketplace open enrollment remains modest.
Continued migration of commercial small group enrollment into the exchanges, expanding access and affordability initiatives as well as the program integrity enhancements net out to a view of mid-single-digit macro market growth in 2025.
Ultimately, we are pleased with the performance of our Marketplace business and believe this market that now serves a strong bipartisan base of more than 20 million Americans can be a powerful platform to expand affordable healthcare coverage and access for individuals across the country.
As we close out year three of our value creation plan, we're pleased with the progress we have made but even more pleased with the second order opportunities we see ahead as we continue to drive operational improvements and mine efficiencies in our business model. This quarter, we advanced work on a project some of you have heard me speak about, namely the use of AI to automate and optimize our management of provider contracts.
By deploying AI within our provider operations, we can reduce the amount of manual labor associated with the installation of new contracts as well as the significant maintenance required for the tens of thousands of existing provider agreements within our portfolio. Additionally, AI will allow us to produce considerably stronger analytics on provider performance, an important lever for advancing initiatives such as value-based care across our business.
Centene's diversified portfolio continues to allow us to navigate unprecedented landscape challenges and build for the future. Our quality team kept the gains from last year's Medicare Advantage Star scores and built on them, strengthening our Medicare platform.
Our health plan and business development teams defended existing contracts and won new ones, expanding the reach of our leading Medicaid franchise. Marketplace continues to deliver value for our members and earnings power for our enterprise, generating important returns and creating a compelling platform to support growth in the individual market. And we continue to find opportunities to get better at the basics and innovate in how we show up to support our members, providers, and regulators.
With the election now 10 days away, I'll highlight again that our product and government relations teams have been preparing for months for the many post-election scenarios that may emerge. No matter the results on November 5, Centene is well positioned as an industry thought leader for maintaining coverage and affordability for Americans across each of our product lines.
The momentum across this enterprise is palpable, and it is a direct result of the efforts of our more than 60,000 CenTeamers, committing their time and energy and talent to improving the health of the communities we serve. To this end, I want to recognize those who showed up to support our members and fellow employees who were impacted by Hurricanes Helene and Milton.
The CenTeamers took immediate and urgent action, including Centene Foundation efforts to deploy much needed financial support to key nonprofit partners in impacted states, headquarters teams coordinating the shipments of over-the-counter medicine and other hard-to-find supplies to our communities in North Carolina and Florida and colleagues opening their homes to fellow employees impacted by the storm. You went above and beyond for our members and each other and showed what it means to be part of the CenTeam. Thank you.
With that, I'll turn it over to Drew.
Andrew Asher
Thank you, Sarah. Today, we reported third quarter 2024 results including $36.9 billion in premium and service revenue and adjusted diluted earnings per share of $1.62. Q3 performance was ahead of our previous expectations and keeps us on track to deliver adjusted diluted earnings per share in excess of $6.80 in 2024.
As you saw in our press release this morning, the adjusted diluted EPS for the third quarter includes $0.10 associated with a marketplace premium tax benefit that we previously expected in the fourth quarter of 2024, so merely a timing shift. The quarter also includes about $0.04 of accelerated income tax benefit. Even without those two favorable timing items, we were still a little ahead for the quarter. Our consolidated HBR was 89.2% for Q3, which brings us to 87.9% year-to-date.
Consistent with our previous public commentary, our Medicaid membership was just over 13 million and our Q3 Medicaid HBR at 93.1% was a little above Q2. While there are still very small pockets of redetermination activity occurring, we largely expect stability in our Medicaid membership around that 12.9 million to 13 million mark as we close out 2024.
With every month that goes by, we continue to make progress with our state partners and their actuaries in our efforts to match rates with acuity. As Sarah mentioned, now 100% of our states have acknowledged and acted. So it's just a matter of sufficiency of rates, state by state, program by program.
We remain confident that this is not a matter of if, but when we get back to equilibrium between rates and acuity. We are pleased and encouraged by the progress since our last call, but there's more wood to chop with our state partners, supported by the irrefutable data we provide.
The commercial HBR of 80% was right on track for Q3, and we showed a little bit more growth with 4.5 million Marketplace members at quarter end, 22% growth from a year ago. We continue to be pleased with the execution in our Marketplace business. And while the open enrollment period hasn't yet started, we believe we can grow during open enrollment and achieve our margin goals in 2025.
Medicare results in the quarter were consistent with our expectations, including a segment HBR of 88.0%. Good execution in 2024 in both our Medicare Advantage and PDP businesses enables us to enter 2025 right on track.
As you saw with the landscape file, we continue to take Medicare Advantage actions designed for the long run, consistent with our strategy focused on low income and dual-eligibles. We exited six of our smaller states that didn't quite match our Medicaid footprint, and we administratively reduced our number of H contracts by about 30%.
While we have much of the annual and open enrollment periods yet to play out, as Sarah covered, we are still targeting $14 billion to $16 billion of Medicare Advantage revenue in 2025. And we are still targeting the same 2025 result that would be consistent with an approximate $125 million of premium deficiency related expense that would be recorded in Q4 of 2024. So overall, no major changes to our Medicare Advantage game plan. Similarly, our Stars game plan is on track at 46% and 3.5 stars for the 2026 payment year, as we covered in our October 11 8-K.
As we've talked about for the last couple of quarters, we expect meaningful revenue growth in our PDP business in 2025, largely driven by the Inflation Reduction Act mechanics. Furthermore, our bids positioned us well, anchored by our outstanding pharmacy cost structure that, when coupled with the CMS demo, facilitates very low cost and attractive products for seniors.
For 2025, we are pleased to again be below the auto-assign benchmark in 33 out of 34 regions; and our zero premium product, inclusive of the federal demo subsidy is available to seniors in 43 out of 50 states.
So we think our reported premium yield will more than double in 2025 compared to 2024 due to the IRA, and we should be able to grow membership as well subject to the annual enrollment period that just started. We are targeting a 2025 PDP margin of 1% or so that we will look to edge up over time, and that is on a much higher revenue base for 2025.
Our adjusted SG&A expense ratio was 8.3% in the quarter, a good result contributing to a slightly better view for 2024. Cash flow used in operations was $1 billion for Q3, driven by a few normal course balance sheet items: one, the settlement of marketplace risk adjustment payables for the 2023 benefit year with a corresponding collection of over $800 million of 2023 receivables expected in Q4; two, Medicaid rate increases not yet collected; and three, an increase in Part D receivables.
Unregulated cash on hand at quarter end was $266 million. During the third quarter plus October, we deployed approximately $1.6 billion on Centene shares for a year-to-date total of $2.4 billion. Our debt to adjusted EBITDA was 2.9 times at quarter end.
Our medical claims liability at quarter end represented 51 days in claims payable, down 3 days sequentially and down 2 days compared to Q3 of 2023. If it weren't for a higher level of state-directed payments in Q3, we would have been at 53 days.
We have updated our 2024 guidance elements to help with your modeling as we look towards wrapping up 2024. Our full-year premium and service revenue was $2 billion higher than previous guidance, which gives us more earnings power for the future.
Our consolidated 2024 HBR guidance of 88.3% to 88.5% reflects the Medicaid insights and updates we have provided you at the last couple of investor conferences. We continue to expect Q3 2024 to be the high watermark for our Medicaid HBR.
2024 SG&A guidance midpoint of 8.6% is slightly down due to cost management and revenue growth. And to round out a couple of other metrics, we expect investment income of over $1.7 billion, excluding gains and losses on divestitures, and depreciation expense in the zone of $550 million. Importantly, we are still on track for greater than $6.80 of adjusted diluted EPS in 2024.
Q3 represents another quarter of good progress, from another divestiture to cost management to revenue growth to Stars and wins in Iowa Medicaid, Pennsylvania LTSS, and Michigan HIDE to boot. Execution in our diversified portfolio enables us to reaffirm our 2024 adjusted diluted EPS guidance of greater than $6.80 despite the temporary Medicaid rate acuity mismatch that we've been briefing you on since May.
As we make forward progress quarter after quarter, we still expect to grow adjusted diluted EPS in 2025 and beyond.
Thank you for your interest in Centene. Rocco, let's open it up for questions.
Operator
(Operator Instructions) Stephen Baxter, Wells Fargo.
Stephen Baxter
I was hoping for the Medicaid MLR, you could potentially provide a little bit of commentary about where you're expecting the fourth quarter to land and any bridging items maybe we should consider, including maybe whether there is any retroactivity in the third quarter, either positive or negative.
And then I guess just a follow-up would be, I'd love to hear you talk about the total level of cost growth that you're seeing in the Medicaid business and where that sits in the second half, trying to understand how much margin impact we should think about the composite rate update you discussed producing. Thank you.
Sarah London
Sure. Thanks, Stephen. So let me tell you a little bit about what we saw in the quarter and what that means for us as we sort of look into Q4 and '25. And really, it is result of the groundwork that we laid out over the last 18 months and what we've shared with you in terms of the proactive dialogue with the states. And I think also a result of being the largest Medicaid provider and being maniacal about data.
And so, as we saw the inflection around the dislocation between rate and acuity start to pick up in Q2, we were very early to call that out. We were very early to bring that to our state partners to show the data and then to continue to refresh that data on an ongoing basis.
And that then became an important input if you think about the 14 states that have rate updates between 7/1 and 10/1. You also heard from both my and Andrew's commentary that one state that we've been waiting for to get an adjustment back to 2023, one of our smaller states.
But that did come through, and therefore, have universality in terms of states acknowledging that there's a need to get rates and acuity together and also demonstrating their willingness to do so. So all of that nets out to the commentary around the composite rate adjustment being in the high 4s to 5% as we think about the year. Also informs the fact that we're encouraged by the momentum that we saw in the quarter and how we think about that influencing the conversations around not just 2025 rates but continuing to push for mid-cycle acuity adjustments.
As you heard from Drew, there's still work to do. But again, the fact that bringing that data forward, leveraging the strong relationships that we have at the state level and being able to push those productive conversations to drive results I think, is sort of what we stand on. I don't know if there's anything you want to add in terms of cost trend or anything.
Andrew Asher
Yeah, Stephen, as you think about the progression from Q3 to Q4, just think about Q3 in Medicaid HBR being the high watermark, as I said in my remarks. And then we've got one pretty big state with a 9/1 renewal and three states with 10/1 renewals and rate updates that obviously will impact Q4 more so than Q3. And then you didn't ask about other lines of business.
But if you step back and think about the HBR in the aggregate, setting aside Medicaid, Q4 seasonally is higher in the Medicare and commercial segments, commercial, typically, because of deductibility and seasonality sort of ticks up during the year. And then in Medicare, usually Q1 and Q4 are a little bit higher than Q2 and Q3. So that rounds out as you think about your modeling from Q3 to Q4 in the context of the aggregate guidance that we provided.
Operator
Josh Raskin, Nephron Research.
Josh Raskin
Just a follow-up on that. Could you speak to core Medicaid utilization trends sort of outside of the acuity shifts, what you're seeing in terms of sort of same-store utilization trends? Maybe specifically comment on behavioral health and maybe the areas you talked about in early September.
And then separately, you said sort of the reverification process is sort of complete in your state. I mean, you're kind of back to the normal procedures around reverifications, how does that change the conversation with the states? Does that have any impact on sort of how you're advocating for rates?
Sarah London
Yeah. Thanks, Josh. There's nothing really new to add relative to the trend conversation from the updates we gave in Q2 and then throughout Q3. So obviously, the major driver of HBR in Medicaid is the mismatch of rate and acuity. And we called out before we have the ability to isolate sort of underlying continuous member cohorts to validate the fact that there is no sort of massive trends sitting in that continuous member book.
There are pockets of trend that are exactly the same as we've been calling out previously, so behavioral health, home health. And then obviously, at a state level, there are those program-specific issues where a state may have changed to the program and needs to give us rate to account for that, which is really normal course blocking and tackling. But in an environment where you have redetermination sort of pressing down on the whole book, those issues become a little bit more visible.
But think about things like adding GLP-1s to the preferred drug list, changing rules around behavioral health access, and changes to prior off ability on our side and sort of cost management techniques. So those are again very consistent with what we've been saying throughout the quarter. We didn't see any new changes as we came out of the quarter.
And then relative to your other comment, we are again seeing states kind of get through the tail of the administrative process. But relative to the rate conversations, those really are sort of aggregate data based.
And so, understanding the impact of what those administrative changes do in terms of the remaining population and then what the resulting acuity is, all of that is -- there's a willingness and appetite by the state to look at that. And it's pretty consistent with the actuarial process because there is a normal look back.
And so, the fact that we're through, again, largely through that tail is not prohibitive relative to the advocacy work that we need to do to make sure that rates are matching what the acuity is netting out to.
Operator
AJ Rice, UBS.
AJ Rice
Just trying to drill down to put perspective on what you guys are saying versus what some of the peers have said. So if your composite rate increases are in the 4.5% to 5% range, and this is the worst for medical loss ratio and you can get better from here, it sounds like, with rate updates similar to that.
Can you sort of parse out -- obviously, that's a blend of the states that didn't update as well as the states that have updated presumably at higher rates. What types of rate updates do you think you need? I mean, we've had others say they need high single-digit updates. One even said maybe low double digit updates. What -- how much do you need to meet your goal of showing consistent MLR improvement going forward?
Sarah London
Yeah. Thanks, AJ. I mean, the answer is obviously different state by state. And as we've said, there's still work to do relative to efficiency. I think the fact -- and we've called this out before about we are in sort of an unprecedented time.
And so, where we have seen the rate adjustments that are outsized relative to what would be normal course all lends itself to the sort of encouraging view that we have that states understand that they need to make up the difference between where the rates may stand for a specific date or specific program and then what we're seeing in terms of the actual experience.
I don't know, Drew, if there's anything you want to add?
Andrew Asher
Yeah. No, we'll just keep forging ahead. I mean, we've gotten rates in the high single-digit range in the very, very small states. So don't get too excited, we got a 10%. But that just gives you the indication of states are looking at the data that we're providing and looking at recent data as well and trying to balance that into their actuarial process.
We're making progress here. We still have wood to chop. We'll be working on that throughout 2025 when we have the 1/1 cohort that we're starting to get visibility on recently, and then moving to 4/1, where we have one big state; and then almost half of our states, 7/1 to 10/1.
Operator
Justin Lake, Wolfe Research.
Justin Lake
I'll just follow up on some of the questions. First of all, on rates, just a clarification. Can you tell us specifically what period we should be thinking about, that 4% to 5% composite covering? Is that the year? Is that second half? And maybe you could share with us just because some of your peers have so we can get a kind of baseline, what's the cost spread that compares to that 4% to 5% that you're seeing now?
And lastly, you've seen a significant pickup in Medicaid pass-through payments. Just want to make sure, is that 4% to 5% you're talking about, including pass-through payments? Or does it net those pass-throughs out? Thanks.
Andrew Asher
Yes. Thanks, Justin, for the questions. So the 4.5% or the high 4s to 5% is the back half rate, so more recent time period. And then we look at that as net rates. And so, pass-throughs would be excluded from that as would programmatic changes to the extent that benefits were adjusted. So we're looking at that as sort of a net fundamental rate even though the gross rates are often a little bit higher depending on the unique state program.
And I would think a bit less as cost trend and more about trying to peg that exit [net] expense PMPM as we exit the redetermination time period and then matching the rates against that exit rate. As Sarah indicated, when we look down into our book of business and look at continuous members, and these are pretty big cohorts that have been with us, I mean, millions and millions of members, so statistically sound, that have been with us for two years. There's not a whole lot of trends.
There's some typical trend in the high acuity populations, reasonable levels of trend and pretty flat in tandem. So I would think of it more as like pegging that exit run rate PMPM, matching rates against it that we'll be working on over the next couple of cycles.
Operator
Sarah James, Cantor Fitzgerald.
Sarah James
Is there a way to size up the pent-up demand portion of trend that would slow as rejoiners flow versus the acuity mix that would continue? And on the GLP-1 flag, can you size how much pressure to trend that is for states that cover it and whether there is a corresponding adjustment in rates or there's a lag there for catching up?
Sarah London
Yeah. So relative to rejoiners, I think as we called out that dynamic and that cohort in particular where, again, in immature months, we're seeing 30% of members who are coming back and as this process has unfolded, an increasing gap in terms of how long it takes for them to come back, which then puts them out of that retroactive reinstatement window is part of what's been contributing to the HBR pressure and delta that you've seen in the last two quarters.
And my commentary about the fact that, that dynamic is slowing, I think, is important. Because those -- the rejoiners tend to come back and find their way back because they are in need of health care. And so again, they create sort of this artificial pressure where they're using the system, and we haven't received premiums for the time period that they weren't enrolled even though they were eligible.
So the more of that we work through and have now worked through over the last couple of quarters means that, that should create a natural tailwind as we turn into 2025.
And then GLP-1s, Drew, maybe you want to talk about the states that have put those on formulary and the data that we can present to them as they think about making sure we get paid for it.
Andrew Asher
Actually, we've had a couple of states that have had GLP-1s available for the [weight] loss indication for a while. So we've got good data. Then we take to other states that are maybe contemplating, should they put it on their formulary, should they not and share that data with them. It also helps shape the rate discussion of -- the ramping of that we saw in those states that have been on it for over a year.
So there's a handful of states. The states can make those decisions, and we administer and then we share data. There's one state that recently added GLP-1s, I believe, as of August. And we're sharing data monthly with them to make sure that the rate that they loaded in, the PMPM rate, their estimate upon the commencement is consistent with the uptake that is being seen in that specific state.
Operator
Andrew Mok, Barclays.
Andrew Mok
Last quarter, you categorized Medicaid HBR improvement as a tailwind for 2025. With a modest setback in Medicaid MLR in the quarter, is it still fair to characterize Medicaid MLR as a tailwind for next year? And what visibility do you have into 1/1 rate updates at this point? Thanks.
Sarah London
Yeah. I would say, yes. Medicaid HBR improvement is definitely a tailwind for 2025. As you heard Drew say, we've started to get some of those 1/1 rates, and we'll have a lot more visibility and obviously be able to update you on 2025 overall at our Investor Day in December. But I still believe we'll be able to grow adjusted EPS, and those headwinds and tailwinds in the aggregate that we've shared previously remain the same
Operator
Lance Wilkes, Bernstein.
Lance Wilkes
Great. I was hoping you could give a little more detail to help our understanding on some of the rates and rejoiner aspects. In particular, with rate increases, as you're doing those, are states doing that by program or at a composite level across programs?
And then when you're thinking about rejoiners and maybe any comments on levers would also be interesting, but rejoiners. Do you have cohorts that are there long enough that you can see a normalization in utilization patterns? Thanks.
Sarah London
Yes. On the -- so first of all, relative to rates, states do -- we get sort of a composite rate, but it's a reflection of a buildup of the underlying sub-programs that are in there. And so they take into account the sort of variety of programs that any of us individually are managing.
And then relative to payers and levers and rejoiners, we do now have, to your point, Lance, rejoined our data -- rejoined our run-out data. and being able to look at and confirm the view that, again, those rejoiners are coming back because they are in need of services.
And then we see the normalization of their utilization patterns thereafter. And in fact, the idea that had we been receiving premiums for those members during the time that we had the gap, it would have normalized their HBR more than what we're seeing.
So that -- all of that, again, continues to confirm the view that it's sort of this artificial pressure that's creating MLR uptick. And then I don't know, anything else on stairs and levers as those continue to run out? No? Yes. So still the same differences that we've been seeing and all of that data gets put into the mix in our advocacy with state partners.
Operator
Adam Ron, Bank of America.
Adam Ron
I appreciate the question. I was wondering if we could get a little more color on the Part D business. You mentioned you expect 1% margin next year. Wondering how that compares to this year.
And then also, one of your peers mentioned that due to the IRA changes that partially took effect this year, they saw a greater utilization shift in some specialty drugs this year because the member cost sharing went down, and that happened after they priced 2025.
And so wondering if you were seeing that and if that had any risk for 2025 or if the voluntary program helps minimize some downside. Any color around all that would be helpful. Thanks.
Andrew Asher
Yeah. Thanks, Adam. No, we're really pleased with our positioning in PDP. So starting with 2024, we're right on track. I mean, we sort of knew the rules of the IRA. We thought about the member change in behavior, which will be different in '25 than '24, but we thought about it for '24 as well and any sort of manufacture behavior changes that might be induced by the changing of the mechanics of the IRA.
So we're right on track, as you can see in our aggregate Medicare segment. But underneath that, PDP is on track and in that same zone of margin for '24. So sort of we expect a degree of consistency between '24 and '25 in the margin, although the revenue will be a lot higher in '25 than '24. So pleased with the positioning. The team did a really good job estimating the direct subsidy.
Obviously, that was a big risk that we talked about going back to Q1 at a conference in March and then on the Q1 call, trying to make sure, quite frankly, that the industry was thinking through all of the elements that needed to be reflected in the bid and therefore driving the direct subsidies. So we would expect to grow in the open enrollment period, the annual enrollment period.
Given our positioning, we're below the benchmark in 33 out of the 34 regions, which is a really good result but consistent with where we've been in the past. And we continue to have zero premium products in the majority of states, in part, thanks to the CMS demo, which brought down that premium by $15.
So pleased with the positioning. Not satisfied with the 1% margin, give or take. But I think that's the right area to a target for '25. And then we'll look to edge that up over the following couple of years.
Operator
Scott Fidel, Stephens.
Scott Fidel
First question, just I was hoping to circle back on Sarah's comment around the expected exchange market growth for next year at the mid-single digits. One of your large sort of ex market-focused peers talked more about a mid-teens growth expectation for next year. And I know you did sort of call out a few sort of regulatory changes for next year.
So it would be helpful maybe if you could maybe walk us through sort of how you would be thinking about like sort of, I guess, the gross marketplace growth and then how some of these regulatory changes may sort of bring that down to the mid-single digits.
Then just my follow-up question would just be around California. One of your peers has commented the last couple of quarters on a retroactive rate adjustment in Medicaid, that's been pretty significant. I know you guys haven't really called that out to nearly the same degree, but just curious on sort of what you've been seeing on that front as well. Thanks.
Sarah London
Yeah. Thanks, Scott, for the question. So long term, we're still very bullish on our view of growth in marketplace, and we called out all of the drivers of that, that sort of increased stability and broker infrastructure, affordability awareness.
As we think about this year, think about the fact that we're coming off of the tailwinds from redetermination. So that creates sort of a natural step down to a more moderated growth rate just to begin with.
And then as you said exactly, the program integrity policies that are being layered in, and really, most of these are just policies that are being reintroduced that were sort of put on pause during the COVID era. One of the new ones is this agent of record lock policy, which requires a member to have a single broker throughout the enrollment period, which again we think creates a more stable enrollment experience. It's something that we put in place starting back in January. So that's not really new for us but maybe new for some folks in the industry.
And then two additional policies that are sort of reinstatement, which is failure to report, which is sort of the IRS policy, making sure that the income level is correct relative to enrollment and the subsidies; and then the flag for overlap between marketplace and Medicaid eligibility. And so, those -- the introduction of those or reintroduction of those relative to this open enrollment is part of what creates sort of that downward pressure in this cycle.
The other thing that I think is important to note is that as we come through the redetermination process, we also anticipate less growth than we've seen in the past couple of years relative to the SEP period.
And so, think about returning to more normal marketplace membership seasonality, which means growth during open enrollment, a peak sometime in Q1 and then sort of natural trailing of membership as you move through the rest of the year. And so, all of that nets out to our view of mid-single-digit growth for the market, our view of sort of more modest this year growth in open enrollment.
But still believe that we will grow in open enrollment. And based on what we've seen -- obviously open enrollment doesn't start for another week, but what we've seen in terms of the competitive landscape, still feel very good about being able to execute our strategy relative to delivering well within our target margins of 5% to 7.5%.
And then, Drew, do you want to comment on the California dynamic?
Andrew Asher
Yeah. Never a 100% sure exactly we're talking about the same thing. But similar to what you described, we were able to get adequate information to get a negative retro into our Q2 results.
Operator
Michael Ha, Baird.
Michael Ha
Just wanted to quickly confirm, on your modest exchange growth expectations, does that imply Centene can grow higher than market to higher than sort of mid-single digit for next year?
And then I know there's been a few questions on Medicaid cost trend already. But just curious, what level of cost trend are you assuming for fourth quarter? Directionally, is it fair to assume your guide sort of implies the 4Q Medicaid trend is higher sequentially? Thanks.
Sarah London
Yeah. So I think, Drew, you covered the seasonality of HBR, but maybe just hit that again in Medicaid.
Andrew Asher
Yeah, Medicaid cost. I think the way to think about that, Michael, is that we expect Q3 to be the high watermark for Medicaid HBR. And yes, every quarter, we assume that there's typical trend in our books of business across all the businesses.
But essentially, what we're doing is exiting the redetermination era at elevated medical expense PMPM relative to a year ago, obviously, and then trending on that going forward, which we expect to have those Q4 -- the benefit in Q4 of the 9/1 and the 10/1 rates. The benefit obviously is much greater in Q4 than Q3.
Sarah London
And then just relative to marketplace growth, so we haven't quantified the target growth, but do believe that we will grow in marketplace. Our strategy really for 2025 has been more about delivering margins well within that pretax range. And so, I wanted to give some color on what we see as overall market growth, and then look forward to providing a more detailed update at our December Investor Day on that front.
Operator
Dave Windley, Jefferies.
Dave Windley
I was going to switch topics to G&A. Sarah, you mentioned AI. And I wondered, I guess, one, if you would be in a position to quantify any of the AI benefits that you might expect to see; and two, are any of those projects shovel-ready at this point?
And then three, on G&A. Are there any timing-related spending items that we should be thinking about on G&A, thinking like offsets to the higher Medicaid MLR, things like that, that we should think '24 versus '25 on G&A? Thanks.
Sarah London
Yeah. I'll let Drew cover timing more broadly relative to year-over-year. The one thing I will call out which you all know is that SG&A naturally goes up in Q4 because we get into our selling periods for Marketplace and Medicare, So just something to keep in mind, but consistent with what you see every year.
Broadly relative to operational efficiency, I think we've delivered great results and created momentum as we think about kind of closing out year three. And as you heard me say, I'm sort of even more excited about the fact that we didn't just deliver on the low-hanging fruit, but really starting to get to the second and third order opportunities, which I think reflects the fact that operational excellence is sort of increasingly baked into the DNA of the organization.
The AI product I mentioned in particular is shovel-ready. But it's -- this is not the beginning. We've actually been layering in the use of AI across different parts of the business as we've come through the value creation work.
And the benefit of doing so much work in terms of standardizing processes means that you can then flip over to automating process, and then you have access to the data allows you to layer in AI and really think about a different way to leverage the size and scale and the data of this organization to drive standardization and administrative processes that aren't necessarily differentiating, and then really focus the talent of the organization on those parts of the process that are differentiating.
So lots of additional non-AI SG&A opportunities. You obviously heard us talk about that relative Medicare. That's going to be another great lever to derisk Stars and drive the path to profitability in that business. But thinking about things like digital payments to providers, vendor consolidation, portal consolidation.
All of these are things that are still ahead of us, and so feel good about the ability to continue to extract EPS improvement, frankly, from that 1% to 2% that comes from margin improvement over time.
Andrew Asher
Yeah. Then we'll bridge you off of the midpoint of 2024 is 8.6% at Investor Day, and it will be somewhat dependent on the mix of business. Obviously, Marketplace and Medicare carry a much higher SG&A load than Medicaid. And then we'll have to weave in the impact of the PDP revenue growth as well. So we'll be sure to do that at Investor Day.
Operator
George Hill, Deutsche Bank.
This is Maxi on for George. The Medicaid PMPM seems to have grown much faster than your peers this quarter. How much of it is driven by rate adjustment? And any other main drivers beyond rate adjustments? And how sustainable is the PMPM growth at this rate going forward? Thank you.
Andrew Asher
Yeah. Thanks for the question. As you heard us talking about cash flow, it's not what you asked about but it's -- there's an interplay here with the cash flows being impacted and the DCP being impacted by state-directed payments that works its way into the yield that you're probably calculating off the face of the disclosures that we have. So there's a fair amount of increase in state-directed payments in the quarter.
And -- but you're right that the high 4s to 5% composite back half rate is helping that as well.
Operator
Thank you. And this concludes our question-and-answer session. I'd like to turn the conference back over to Sarah London for closing remarks.
Sarah London
Thanks, Rocco. I'll just close out by emphasizing what I think you've heard this morning, which is our business objectives and expected 2024 earnings power remain unchanged. We are pleased to be making progress matching Medicaid rates with acuity and generating positive momentum on RFP wins in the meantime.
Relative to Medicare, we are marking gains on important strategic initiatives there, and we continue to lead in our marketplace business, which is a product where I think our depth of experience and execution is unparalleled.
So we still have work to do. We still have a lot of opportunity ahead and look forward to updating you again at our upcoming Investor Day in December. But in the meantime, thank you for your interest in Centene, and I hope you have a great weekend.
Operator
Thank you. This concludes today's conference call. We thank you all for attending today's presentation. You may now disconnect your lines and have a wonderful weekend.
