Full Report
Oscar Health, Inc.'s management explains the business in its own materials. The slides below do the most of that work, pulled from the documents preserved in Sources. Each source link opens the complete presentation at that slide in a new tab.
4Q and Full-Year 2025 Fact Sheet — FY2025
A three-page fact sheet issued with 4Q25 results — current scale, 2026 guidance and the margin story in management's own framing. · Open the full document →
Investor Day 2024 — 2024
Oscar's most complete public explanation of itself: strategy, market structure, unit economics and the 2027 targets management set. · Open the full document →
Investor Day 2022 — 2022
The earlier investor day, kept for what it explains and nothing since has: the P&L mechanics, the technology stack and +Oscar. · Open the full document →
More from management
J.P. Morgan Healthcare Conference 2024 — 2024 · 9 pages · The same story compressed into nine slides five months before the investor day, with a member-provider flywheel diagram. · Open →
Fourth Quarter and Full Year 2022 Earnings Presentation — FY2022 · 13 pages · The last full quarterly earnings deck Oscar published: FY2022 results and the original 2023 guidance. · Open →
J.P. Morgan Healthcare Conference 2023 — 2023 · 11 pages · How the path to profitability was framed entering 2023, under the prior CEO and before the ICHRA pivot. · Open →
Oscar Health, Inc.'s management answers for the business every quarter. These are the exchanges that explain it best — verbatim, from the call transcripts preserved in Sources. Each link opens the full transcript at that page in a new tab.
Q1 2026 Earnings Call — Q1 FY2026
The first quarter after the subsidy cliff, and the clearest current account of how risk adjustment, churn and the new marketplace business work. · Open the full transcript →
Why a seasonally light claims quarter mechanically inflates the risk adjustment accrual — the offset that drives Oscar's MLR.
Scott Blackley (Chief Financial Officer): I want to spend a moment on risk adjustment. Medical claims were seasonally low in the first quarter, and as a result, we recorded a higher risk adjustment accrual. It is early in the year, but we are encouraged by the data we are seeing on overall market contraction and market morbidity. Our claims experience, coupled with third-party data on both new and renewing members, points to market morbidity tracking in line to favorable to our pricing expectations. We continue to expect risk adjustment as a percentage of direct premiums to be approximately 20% in 2026 as new members engage with their benefits and members meet their annual deductibles.
p. 2 · Read in context →
The 200,000 members lost between February and April were mostly never-payers, so they brought almost no claims with them.
Jessica Tassan (Piper Sandler); Scott Blackley (Chief Financial Officer): I guess my first one is just can you describe the first quarter behavior of the 200,000 or so members who fell off between 1Q and April 1? I'm curious if they were pulling utilization forward into the base period or if they just kind of didn't utilize—were they not aware they had coverage? And then can you just describe the accounting for any expenses incurred by that population in your first quarter results? […] So I would say that for members who churned off, there was nothing unusual about any of the utilization patterns that we experienced in the first quarter. And those members, in general, the biggest portion of the drop-off really are people that never made a payment. And so we would not expect to see a significant amount of utilization for people that aren't paying. And once that person goes into a delinquent status, we no longer pay claims—you have to pay in advance in order to be covered. And so once you go into delinquency, we wouldn't expect to cover any claims that might be incurred. So really, everything that we saw in terms of member transition going from 3.4 million to 3.2 million and then starting the second quarter with 3 million members proceeded exactly as we expected.
p. 3 · Read in context →
Operating leverage is real — but 9% to 10% of premium is a fixed toll for being in the market at all.
John Ransom (Raymond James); Scott Blackley (Chief Financial Officer); Mark Bertolini (Chief Executive Officer): Just wanted to ask a question about SG&A. So your revenue was suppressed by almost 400 basis points by your risk adjustment versus the 20% guide, but your SG&A was 15.2%. Why would SG&A go up if presumably you're going to get a revenue lift for the rest of the year with a lower risk adjustment hit to revenue? […] I appreciate the question. We saw obviously strong revenue growth—revenue growing at 53% based on the headline numbers, higher than that if you normalize for the risk adjustment. SG&A grew at 46% in terms of SG&A dollars. So we are clearly seeing leverage coming through. I would say the first quarter SG&A ratio is likely to be the lowest for us during the course of the year. There's a little bit of a dynamic as we grow membership and have some open positions at the beginning of the year. There's a natural flow as we normalize the busines for the higher membership. So we'll see that kind of growth throughout the quarter. I woul think that from here, we'll probably see the SG&A ratio moving sideways to slightly up. The fourth quarter tends to be a little bit higher as we start to pick up expenses associated with open enrollment efforts. So I continue to think that there's a lot of opportunity to continue to drive performance and improvements in SG&A even at the low levels that we achieved in Q1. […] And I'd add, John, that taxes and fees are pretty much fixed for us based on the level of membership. It's 9% to 10%. So we're looking at the variable piece that we can manage versus that fixed piece, which is essentially a tax for being in the game.
p. 4 · Read in context →
A rare walk through the reserving judgement behind one quarter of prior-period development, adverse states included.
Jonathan Young (UBS); Scott Blackley (Chief Financial Officer): Just going back to the risk adjustment again. Would you say the risk adjustment was more a function of the claims data that you're seeing so far? And to be sure, there's no sweep or cleanup related to 2025 accruals within that? And then alongside that, did the Wakely data influence how you came to the 24% figure? […] Take those two things separately. The 24% risk adjustment level is explicitly being driven by our claims experience. Our risk adjustment reserves are still based on the market morbidity assumptions that we went into pricing with and that we set our guidance with. We have not made any adjustments for some of the favorability that we see in the Wakely market morbidity report, so again, that could be a tailwind, but we're waiting to see more signals before we lean into that. On prior period development (PPD), in the last weekly report we received for 2025, we did see a couple of states that had adverse development totaling about $85 million. We reflected that in the quarter. We did have some other states with positive developments, which we chose not to recognize and instead wait for the final report. So we feel like we balanced the risk in that area. We also had favorable claims run out to a significant degree of $150 million. Net-net, our prior period development was favorable $68 million in the quarter. When I look at the combination of those factors, favorable prior period development is helpful, and we used those risk levels and reserve levels in building our pricing for 2026. We think those tailwinds will transition beneficially over the year.
p. 6 · Read in context →
The economics of the new Lucie marketplace: higher margin per dollar than an insured member, and no risk capital behind it.
Olivia Miles (Baird); Mark Bertolini (Chief Executive Officer); Scott Blackley (Chief Financial Officer): I'll give some headlines now and go into more depth at Investor Day in September. As we talk to employers around the country, including increasingly larger employers interested in ICHRA solutions, they care a lot about networks. While an individual shopper wants to select their network, we're inviting competitors to the platform because an individual can select among different plans. That matters because you're converting an entire employer. On the economics, converting to an employer solution means you have to meet other benefit solutions. We have companies like Allstate Health and Aflac and Guardian joining our platform to provide ancillary products. More importantly, the margin from a dollar standpoint for these employer relationships is higher than an insured ACA member and it's unregulated in that it doesn't require risk capital. It's another margin opportunity to grow both top and bottom line over time. We're excited about the model and are assembling it, and having many partners on the platform allows us to share networks and offer narrow network rates that are very competitive given combined purchasing power. We'll provide more detail in September. […] Any of the costs to stand up that business are included in our guidance. For this year, we would expect a modest effect, but we're excited about the prospects of building a fast growing, high-margin business.
p. 7 · Read in context →
How Oscar took share in the 2026 enrollment: brokers pre-loaded with member lists and mapped replacement plans.
Raj Kumar (Stephens); Mark Bertolini (Chief Executive Officer): I'd explain that by distribution. It's hard to know exactly where all new members came from, but we did pick up some auto-assigned members from a competitor that left the marketplace. When we did our Investor Day two years ago, we assumed there would be no enhanced subsidy extension and built our plan accordingly. That allowed us to prepare products that would mitigate cost increases for members, and we built tools that allow brokers to set aside what they needed to retain members. For brokers, it's about maximizing capacity to sell and retain. We gave them products and lists of members and product recommendations. Many competitors were stuck between expectation of enhanced subsidies or not and didn't make the plays we made on product. Brokers, seeing our solutions, brought members to us. Our enrollment growth was almost a straight line up over the first three to four weeks when enrollment opened because our brokers were ready, had already talked to clients using our technology, and were able to get them signed up efficiently.
p. 8 · Read in context →
Metal mix is not what drives risk transfer — the formula adjusts for it. Total utilization is what matters.
Craig Jones (Bank of America); Scott Blackley (Chief Financial Officer): So I think your member mix, when you think about the Bronze members, I think it went from a little below average in 2025 to now a little above average in 2026 versus the market. With that mix shift toward Bronze versus average, how does that impact your risk adjustment payable year-over-year? […] Our book is relatively balanced: Bronze is our largest category, Silver close second, Gold a significant portion as well. The risk adjustment formula is intended to be neutral across metal levels: coefficients in the formula adjust for the expected claims and condition values of different metal tiers. So risk adjustment isn't driven entirely by metal mix. What's more important is overall utilization across metals. We tend to attract relatively healthier members given the products and markets we're in—urban areas that skew healthier on average. We do think you see healthier members in Bronze than in Silver, for example, but across all metals we expect strong margin performance and view risk adjustment as more driven by overall utilization than any one metal.
p. 8 · Read in context →
Q4 and Full Year 2025 Earnings Call — Q4 FY2025
The reset-year post-mortem and the 2026 rebuild: how the book was repriced, what growth costs in capital, and what management still could not predict. · Open the full transcript →
The 2026 rebuild in one passage — price to the high end of expected contraction, refile rates across 99% of the book.
Scott Blackley (Chief Financial Officer): Our disciplined pricing assumed and expected market contraction at the high end of our previously communicated 20% to 30% range driven by the expiration of enhanced premium tax credits and CMS program integrity initiatives. We also refiled rates in states covering approximately 99% of our membership to reflect the higher market morbidity in 2025. Together, these actions position us to profitably drive share growth. For 2026, we expect total revenues to be in the range of $18.7 billion to $19 billion, an increase of 61% year-over-year at the midpoint, driven by another year of above market growth during open enrollment, solid retention, and rate increases. While our weighted average rate increase for 2026 was approximately 28%, the increase on a per member per month basis is lower, reflecting shifts in member age and metal mix.
p. 3 · Read in context →
The rule of thumb that governs how fast Oscar can grow: roughly $50 million of capital per $1 billion of premium.
Scott Blackley (Chief Financial Officer): To help frame our capital position in the context of our growth outlook, I want to spend a moment on regulatory capital requirements. While individual states vary, a useful rule of thumb is that for every $1 billion of premiums, we are required to hold approximately $50 million of capital, which reflects roughly 55% quota share reinsurance ceding percentage for 2026.
p. 4 · Read in context →
The hardest question on the call — who pays a first premium and then quits? — answered with candid uncertainty.
John Ransom (Raymond James); Mark Bertolini (Chief Executive Officer); Scott Blackley (Chief Financial Officer): I have a basic question that might not reflect well on my intelligence. I understand passive enrollment, but you need to pay the first premium to be covered. So, what type of member gets passively renewed, pays the first premium, and then chooses to drop off? […] That is the key question this year in comparison to previous years. Typically, once customers begin paying a premium, they remain with us unless an event occurs that makes them no longer need our coverage. However, in the current situation, as they assess the out-of-pocket expenses related to their plans, they may realize that it's too costly and unaffordable. An important change is that most Americans now view healthcare as the largest expense in their household budgets, even more significant than their mortgages. This has led many customers to fear losing their homes or facing bankruptcy without coverage. The pivotal question is what happens if they cannot afford the deductible and how we will address that issue. We're examining whether this situation will drive enrollment or if people will remain enrolled out of fear of losing their homes or facing financial hardship. We're uncertain, so we are cautious about predicting the degree of disenrollment that may happen as a result. […] John, just to add one more dimension there. When you look at our expectation and what we'r seeing on payment rates, if you're going from having an out-of-pocket premium that you wer paying in 2025 to having an out-of-pocket premium that you're paying to '26. And you have actively enrolled and even passively enrolled. We're seeing relatively strong payment rates in those categories. It's really the population where you're going from a $0 plan to something that you've got to pay out of pocket. So you've either lost your subsidy or you've transitioned from one plan to another. That's where we expect to see really high nonpayment rates. And the way the whole process works, you may not make your first payment in January, but you don't ultimately churn off until the end of the quarter because you are in a grace period until then.
p. 8 · Read in context →
The metal shift quantified — silver roughly halved, gold up several-fold — and why premium per member lags the headline rate increase.
Stephen Baxter (Wells Fargo); Mark Bertolini (Chief Executive Officer); Scott Blackley (Chief Financial Officer): Sure. For Bronze, the percentages for the past two years were around 25% and 26%, and now they are at 39%. Silver has remained steady at 71% over the last two years, and this year it’s at 36%. Gold, which was in the low single digits at 3% or 4% for the last two years, has now risen to 25%. There are fairly significant changes. The bronze and gold plans we offered were $0 with benefits that are not very rich. […] Stephen, the other thing I would just mention is that the characteristics of the membership are important to modeling your revenue. So the fact that we're seeing a year younger membership has an impact on PMPM revenue. So you need to factor that in. That's one of the reasons why I discussed that in the call is to help with your ability to project revenue with that information.
p. 9 · Read in context →
The CFO names risk adjustment the hardest estimate he makes each quarter, because no single carrier can see the market.
Olivia Miles (Baird); Scott Blackley (Chief Financial Officer): Because exchange marketplace risk adjustment is net neutral, creating a reliance on other plans in our markets, the lack of visibility any one plan has into the rest of the market makes risk adjustment mechanics difficult in our view. Looking to 2026 and beyond, you mentioned the potential Wakely industry report in 1Q, whether it's through this potential Wakely report or other efforts, can you share how you're getting more insight into the rest of the market as well as your thoughts on what can be done to make risk adjustment more transparent and less volatile in the future? Is there any potential reform you think could be done to improve risk adjustment? […] Thank you for the question, Olivia. Estimating risk adjustment is indeed the most challenging task we face each quarter, as it involves projecting our own performance as well as market trends. While we are confident in our ability to forecast our own book's performance, we often encounter surprises due to unexpected market movements. I am hopeful that by collaborating with Wakeley, which many of us in the industry are using as a key service provider, we can gain more timely insights into the market. This is crucial for improving our projections. We are making progress in this area, and while we may not achieve complete clarity in the first report, I believe that with support from various industry players, we can enhance visibility on these estimates over time.
p. 10 · Read in context →
Where ICHRA is meant to lead: a second revenue line from converting employers to defined contribution, without risk capital.
Mark Bertolini (Chief Executive Officer): From a micro perspective, we are focusing not only on products to capture membership within the insurance company, but we've also developed the front end of the business to engage with employers and convert them. There are significant revenue opportunities, particularly in higher-margin areas that do not require risk capital, by assisting employers to transition employees into defined contribution plans. Once employees are in defined contribution, we can collaborate with brokers to direct them to suitable plans, whether they are Oscar plans or not. Over time, you will see us reporting two types of revenue: one from the conversion of employers to defined contribution and the associated brokerage work, and the other from membership within our health plan. The ICRA opportunity is much broader than just membership, though our membership doubled this year. Due to recent events in the individual market regarding rates, some employers have been hesitant to participate at this time. We need to demonstrate that we can stabilize the marketplace and attract more members. This outlines the current situation regarding ICRA.
p. 11 · Read in context →
Q3 2025 Earnings Call — Q3 FY2025
The pricing-cycle call: a 28% weighted average rate increase, where it left Oscar competitively, and the plainest statement of what it actually underwrites. · Open the full transcript →
Who the individual-market customer is, and what the enhanced subsidy is worth to them in dollars per month.
Mark Bertolini (Chief Executive Officer): The individual market is the only source of affordable health coverage for 22 million Americans who power our economy. The majority of members are from the small businesses, service, and farming sectors, which together generate nearly half of U.S. GDP. These hardworking people do not have access to employer coverage and rely on enhanced premium tax credits to fill the gap. For example, the average farmer making $60,000 a year now pays $75 a month for health insurance compared to $300 a month before the enhanced premium tax credits. That $225 is the difference between paying for health care or paying the bills. Limiting access to affordable coverage in the individual market undermines Main Street and rural America.
p. 1 · Read in context →
How the 2026 price was stacked, and the claim that underlying MLR ex-morbidity was still near the original guide.
Jessica Tassan (Piper Sandler); Mark Bertolini (Chief Executive Officer); Scott Blackley (Chief Financial Officer): Got it. And then just maybe do you have any early thoughts on how Oscar's morbidity in 2026 might evolve relative to the market? Or maybe just anything in your pricing or product design or commercial strategy that you'd call out that would give you maybe more control over your morbidity relative to the market? […] Well, on the first point, we have priced as if premium tax credits are gone. The '25 impact of morbidity, '26 potential impacts on morbidity given the shrinkage of the market, which we think is anywhere between 20% and 30%. 20% is the lower end without a number of these things, 30% being the highest, but that has an impact on our morbidity and program integrity efforts as if they were implemented. And we stack those in our pricing. We did not look for any duplication. And so we believe we're well-covered depending on whatever happens next year relative to the morbidity in the market. Anything to add on that, Scott? […] No. And I think it's too early to say much about '26 morbidity. I think that when I look at the core performance of the company this year and I strip out kind of what happened with the impacts of market morbidity shifting higher this year, we're really pleased with the underlying trends, right? We're seeing an MLR when I strip out kind of the impact of what was happening with market morbidity, the underlying MLR is pretty consistent with the guidance that we gave at the beginning of the year in the low 81% range. And so when I step back from that and look at the dynamics in the company, our ability to influence what's going on with our medical expenses, we feel like we're really well positioned to continue to navigate this marketplace. And as Mark talked about, we feel like our pricing captures the risk. We feel like the company is getting ever better at delivering our services. So we feel really well positioned for '26.
p. 6 · Read in context →
Competitive position made concrete: lowest or second-lowest silver in 15% of markets in 2025, 30% in 2026.
Stephen Baxter (Wells Fargo); Scott Blackley (Chief Financial Officer): I guess the first question would just be trying to dive into the competitive dynamics a little bit more for next year. It seems like maybe some of your large peers have rate increases that are at or maybe above your 28%, but then maybe some of the not-for-profits could be a little bit lower. Just to kind of boil it down, like is there any kind of metric you have where you kind of have an analysis of what percentage of your markets you're going to be in a low-cost position, either just in the silver market or maybe across all your markets and how that compares to 2025? […] Steve, so when we think about competitive position relative to last year, first of all, all these increases in prices, you've got to start with last year's price position where last year, we were only, I think, in 15% of our markets, we were the lowest or second lowest silver price plan. This year, that's moving up to 30%. We still think that, that's less than some of the other large competitors that we see in the marketplace. So while we're competitive, we're not as competitive as some others. When I think about that relative price position, we think we can grab share in several of these markets. We think that the average price increase nationally is around 26% based on research by the Kaiser Family Foundation. So we think that we've done a nice job of putting our pricing into the market in a way which is competitive, allows us to grow margin, but also is disciplined and allows us to protect ourselves as well.
p. 7 · Read in context →
Asked why grabbing share into a shock is right, Bertolini explains Oscar underwrites the network, not the member.
Andrew Mok (Barclays); Mark Bertolini (Chief Executive Officer); Scott Blackley (Chief Financial Officer): You mentioned that your competitive pricing was in line with expectations and that you expect to take market share next year. Can you help us understand that strategy a bit more? Why is taking market share the right strategy in 2026? And do you think that is more likely or less likely to hurt from an adverse selection standpoint? […] Taking market share involves capitalizing on competitors who have priced themselves out of the market. There is an important distinction between the group market and the individual market that I hope is clear. Due to the risk adjustment system and its mechanics, underwriting members in the network is nearly impossible or simply not worth the effort. Our focus is on the provider network itself and how we underwrite that network. Some of our competitors, who have set much higher prices or exited the market, are relying on commercial networks at those elevated prices, while we have consistently utilized narrower networks. In the individual buying process, consumers have the freedom to choose a network and plan design that best suits their needs, instead of receiving a costly broad network plan from their employer that may not adequately meet anyone's specific requirements. Consequently, we see a chance to capture market share from those pricing themselves 30% to 40% higher than us, integrating those consumers into our networks and underwriting strategies to enhance our effectiveness. Our pricing strategy reflects the actual costs of the network, as we benefit from the risk adjustment aspect. […] I want to reinforce what Mark mentioned earlier. We see clear indications of a very rational marketplace. We don't believe anyone has attempted a land grab by significantly lowering prices. We think we're positioned appropriately within the market. Therefore, from an adverse selection standpoint, that isn't a major concern for us.
p. 9 · Read in context →
On the marketplace-fraud debate: Oscar's own dual-eligible exposure came in at low double-digit thousands, not millions.
Mark Bertolini (Chief Executive Officer): And one more thing I'll add is that we are very supportive of the program integrity efforts and the things that happened this year in program integrity had less and less impact on us as an organization than others because we spend a lot of time validating as much as we can the membership that comes into our plan. And if we see what we see as potential fraud, we sideline those brokers and those members and evaluate whether or not it's appropriate to bring them on board. So given that, when we received our dual eligible information, it was low double-digit thousands, very low double-digit thousands versus the headline report put out by certain people in the press of 2.4 million people. And so the obvious impact to us was a lot less than we thought it was going to be because we had done the homework upfront. We think this is a key part of making sure risk adjustment works well is that everybody uses these same tools to make sure that the people we're bringing on board belong on board, not because somebody else was able to get commission.
p. 10 · Read in context →
Q2 2025 Earnings Call — Q2 FY2025
The quarter the thesis was tested: a $316 million risk adjustment true-up, a swing to a full-year loss, and the first defence of the balance sheet. · Open the full transcript →
The diagnosis of the shock: sicker entrants from Medicaid redeterminations, healthy low-utilizers leaving on program integrity.
Mark Bertolini (Chief Executive Officer): Let's start with recent market dynamics. The latest risk adjustment data from Wakeley, which includes claims data through April 30, indicates a meaningful market-wide increase in morbidity in 2025. This morbidity shift is impacting all carriers, increasing by mid- to high single digits across Oscar's markets. We attribute market morbidity increases to consumers entering the individual market for Medicaid redeterminations and healthier, low-utilizing consumers leaving the market in part due to program integrity efforts.
p. 1 · Read in context →
Where the marketplace strategy starts: a brokerage, a CMS-approved enrollment platform and the first branded ICHRA plan.
Mark Bertolini (Chief Executive Officer): We are announcing several strategic steps to power ICHRA and further diversify our business. We acquired important early-stage assets with capabilities to help us build the consumer marketplace of the future. These assets include an individual market brokerage, a direct enrollment technology platform, and a consumer education website, healthinsurance.org. We are also launching a new ICHRA product with a well-known consumer brand in the Midwest, Hy-Vee, Inc. Our new ICHRA assets will give us capabilities to meet and exceed the expectations of consumers and employers. The technology platform, INSXCloud, is a fundamental asset of the marketplace as it is one of only 11 CMS-approved solutions, creating a digital storefront for all health products. The brokerage, IHC Specialty Benefits, offers individual medical and supplemental health products across carriers in all 50 states. The brokerage will allow us to offer consumers the supplemental health products they typically buy with health insurance. While the acquisition will not have a meaningful impact on our near-term results, we believe these capabilities are important building blocks of our long-term strategy. Hy-Vee is one of the most trusted brands in the nation with 570 grocery and convenience stores and 270 retail pharmacies. Hy-Vee and Oscar are introducing a new Hy-Vee Health branded ICHRA plan. We are initially launching this product for employers and employees in Des Moines, Iowa, for plan year 2026, subject to state approval. The plan offers superior benefits, including concierge medicine at an affordable fixed price through Hy-Vee Health Exemplar Care clinics. Our partnership is an example of the innovation we intend to drive with other employers, provider systems, and consumer brands in the United States.
p. 1 · Read in context →
Restating the first half on a consistent accrual shows how much of the damage was timing rather than claims.
Scott Blackley (Chief Financial Officer): The second quarter MLR was impacted by an incremental $316 million increase to our risk adjustment payable for 2025, driven by higher ACA marketplace morbidity that increased by more than our prior estimates. We recognized the year-to-date impact of the risk adjustment change in the second quarter. Applying the revised risk transfer accrual consistently across the first half would have resulted in an MLR of 80.7% in the first quarter and 85.1% MLR in the second quarter.
p. 3 · Read in context →
Can the balance sheet absorb the loss? The answer separates subsidiary excess capital from parent cash.
Joshua Raskin (Nephron Research); Scott Blackley (Chief Financial Officer): Yes. Well, Josh, let me start with your question about cash. So as we talked about in the prepared remarks, we feel like we've got a very strong capital position at this point, $5.4 billion of total cash and investments, $579 million in excess capital and $205 million of cash at the parent. The vast majority of the cash and investments are in our insurance subsidiaries, which more than covers the risk adjustment payable as well as our required capital, and that's where you end up with the excess capital. We think that the bulk of the remaining losses that we're forecasting for this year are going to be absorbed by that excess capital position. And so you saw that our excess capital decreased by about $300 million from last quarter, and that was the subsidiaries absorbing the losses in the second quarter. And with respect to parent cash then, I do think that parent cash will decline in the back half of the year, largely due to us making some additional capital contribution to the insurance subsidiaries where we don't have as much excess capital. But we feel confident that parent cash is going to be at levels that remain more than sufficient to cover the cost of the holding company and the things that we need. So we feel really good about where our capital position was going into this change in market morbidity and are confident that we've got the access to funding that we need to continue to run this company.
p. 4 · Read in context →
Pressed on the 2027 targets in the middle of the shock, Bertolini declines to withdraw them.
Joshua Raskin (Nephron Research); Mark Bertolini (Chief Executive Officer): How should we be thinking about your previous long-term targets for 2027, specifically the 5% margin and the $2.25 of EPS? […] Well, we're not changing our longer-term forecast at this moment, but 5% is still our target. We need to get through this pricing season, see how the membership is going to develop as we then look at '26, '27, and '28, we'll revise as necessary. But at this point in time, we're not changing our point of view.
p. 4 · Read in context →
Q4 and Full Year 2024 Earnings Call — Q4 FY2024
The high-water mark: first profitable year, the 2027 margin target, and the definitions — effectuated versus paid, price versus trend — a reader needs to follow everything after. · Open the full transcript →
The first profitable year, and the long-term frame every quarter since has been measured against.
Mark Bertolini (Chief Executive Officer): This afternoon Oscar reported the strongest year of financial performance in our history. Our results were driven by record high membership, bottom line profitability, and continued product innovation. Oscar reached two significant milestones in 2024. First, we reported total company adjusted EBITDA profitability growing to $199 million, a $245 million year-over-year improvement. Second, we achieved net income profitability. Net income was $25 million, a $296 million increase over the prior year. Our improved bottom line was driven by strong performance in all parts of our business. We grew total revenue by 57% year-over-year to $9.2 billion. Our medical loss ratio was stable year-over-year increasing 10 basis points to 81.7%. We also drove greater efficiency in our business as our SG&A ratio improved more than 500 basis points year-over year to 19.1% through operating leverage and disciplined expense management. Our 2024 performance reflects the strength of our strategic plan and our ability to deliver long-term profitable growth. Overall, 2024 was an exceptional year for Oscar. Our results reflect our growing maturity as a company and we are committed to delivering at least 20% revenue CAGR and a 5% operating margin by 2027.
p. 1 · Read in context →
A year before the shock, a Q4 MLR miss is already attributed to market risk scores rather than utilization.
Josh Raskin (Nephron Research); Mark Bertolini (Chief Executive Officer); Scott Blackley (Chief Financial Officer): Just I’ll start with one point that I think is really important to understand. Our utilization came in as expected actually slightly better. So what you’re seeing in the change of the MLR is not worsening utilization, it’s the relative risk of our book versus others and the impact of risk adjustment settlements at the end of the year. […] So, I think that on the MLR, I’ll start there. So for MLR, as Mark just talked about, what we have seen is utilization actually came in slightly favorable to what we would have anticipated. And we saw risk or development proceeding as we would have anticipated based on the claims that we’ve had. And when we got the fourth quarter risk report from our friends at Wakely, we observed that in several markets there had been an increase in the risk scores of the market versus what we were expecting. So we took that information and updated our accruals for that. So that is really what drove the pressure in MLR. It also, as a result, when you increase your risk transfer, it also drove a shortfall in revenue. So it was the same thing driving both those effects. I would also point out that we had favorable prior period development in the fourth quarter, which offset some of the pressure from the risk adjustment true-up. And those same drivers had an effect on the full year MLR, but to a lesser degree.
p. 5 · Read in context →
How margin is constructed: price the trend, then earn the spread with affordability initiatives.
Jessica Tassan (Piper Sandler); Scott Blackley (Chief Financial Officer): Yes. Well, I would say that, first off, we always take an approach to pricing, which is we want to have a disciplined pricing strategy that balances our desire to both grow the book and to create margin for us, so that's kind of thing one. When we think about the different pricing for each of the metal tiers, we do that primarily with the view of we want all of our book to perform in a way that creates margin for the business, so that's probably the most important lens. So, we build up what do we think the trend is going to be and then we create margin by basically having affordability initiatives that allow us to experience an MLR that is below the or experience an increase in medical costs that is below the trend, so that's kind of what we do there.
p. 8 · Read in context →
What a $0-premium member is actually buying — catastrophic protection, not care.
Mark Bertolini (Chief Executive Officer): What we have found in a number of our zero premium plans, there are a large number of members that don't use care at all that significantly. And that's largely as an insurance policy for them in case there's an accident or someone gets ill; they don't lose the house. So it's a very different purchasing decision. They're buying a plan at zero premium that gives them some coverage for catastrophic events.
p. 8 · Read in context →
More calls
Q1 2025 Earnings Call — Q1 FY2025 · 8 pages · The last clean quarter before the reset, and the one place management decomposes the record 15.8% SG&A ratio into fixed leverage, variable savings and exchange fees. · Open →
Q3 2024 Earnings Call — Q3 FY2024 · 8 pages · The 2025 pricing cycle in a calm market — roughly a 6% rate increase against a 7% market — the baseline against which the 28% increase for 2026 should be read. · Open →
Q2 2024 Earnings Call — Q2 FY2024 · 7 pages · The first quarter reported against the June 2024 Investor Day plan, including the SEP-membership economics that carried 2024 growth into 2025. · Open →
Q1 2024 Earnings Call — Q1 FY2024 · 7 pages · The pruning that made Oscar a pure individual-market bet: exits from Medicare Advantage and the Cigna+Oscar small-group venture, with ICHRA named as the replacement. · Open →
Q4 and Full Year 2023 Earnings Call — Q4 FY2023 · 9 pages · Bertolini's three-priority turnaround framework and the 2023 insurance-company EBITDA milestone — the starting point of the profitability story. · Open →
Q3 2023 Earnings Call — Q3 FY2023 · 7 pages · The path to 2024 total-company profitability set out mid-turnaround, plus the county-level expansion logic behind the 2024 growth. · Open →
Q2 2023 Earnings Call — Q2 FY2023 · 11 pages · Bertolini four months into the job, with Sid Sankaran still CFO, giving his first read on what he found inside the business. · Open →
Oscar Health, Inc.'s annual reports contain management's most considered account of the business. These are the sections, passages and visual pages worth opening in the originals preserved in Sources.
Oscar Health, Inc. — FY2025 Annual Report (Form 10-K) — FY2025 (year ended December 31, 2025)
The latest 10-K: 2.0m members, $11.7bn revenue, a $443m net loss, MLR 81.7%→87.4%, and a $2.53bn net risk adjustment payable. · Open the full document →
Item 1. Business — Our Business and Our Offerings — p. 7 · Read the full section →
Management's definition of a now single-line business: ACA individual plans, with 93% of 2025 premium paid directly by CMS.
What Oscar sells after exiting Medicare Advantage and Small Group, and the three 2025 ICHRA acquisitions.
Oscar is a leading healthcare technology company built around a full stack technology platform and a relentless focus on member experience. We offer health plans through the ACA serving individuals, families, and employees. We have been challenging the status quo in the healthcare system since our founding in 2012 and are dedicated to making a healthier life accessible and affordable for all. Our technology drives superior experiences, deep engagement, and high-value clinical care, earning us the trust of approximately 2.0 million effectuated members, as of December 31, 2025. […] In 2025, we also acquired early-stage businesses with capabilities to help us power Individual Coverage Health Reimbursement Arrangements (“ICHRA”) and further diversify the Company. These assets include Lucie, Inc. (f/k/a INSXCloud, Inc.), a direct enrollment technology platform; IHC Specialty Benefits, Inc., an individual market brokerage; and Healthinsurance.org, LLC, a consumer education website. […] Oscar's health plans are offered in the individual market. The individual market primarily consists of policies purchased by individuals and families through health insurance marketplaces, established by the ACA and operated by the federal government, as well as other marketplaces operated by individual states (collectively, “Health Insurance Marketplaces”). Individuals and families may also purchase policies in the individual market off-exchange. Employees whose employers have chosen to offer an ICHRA are also able to purchase Oscar’s health plans.
p. 7 · Read in context →
Item 1. Business — Our Strategic Focus — p. 14 · Read the full section →
The forward bet in management's words: ICHRA displacing employer group coverage, which is what the 2025 acquisitions were bought to serve.
The stated long-term vision and the ICHRA thesis the 2025 acquisitions were made to support.
Our long-term vision is to build the consumer marketplace of the future and lead the individual market. We built our strategy around several core trends in healthcare, including rising consumer and employer healthcare costs, consumerization, digitization, and the shift towards personalization. Over time, we have been observing the overall healthcare system move towards these trends, which not only validates our strategy, but provides us with a first mover advantage. […] We continue to believe ICHRA will disrupt employer group coverage and expand individual insurance beyond the traditional ACA market. Our goal is to position Oscar as the preferred carrier for employees enrolling in health insurance through an ICHRA program. […] The businesses that we purchased in 2025, including Lucie, Inc. and IHC Specialty Benefits, Inc., provide important building blocks to support our ICHRA strategy and long-term vision to build the leading consumer health marketplace.
p. 14 · Read in context →
Item 1A. Risk Factors — Our success and ability to grow our business depend in part on retaining and expanding our member base. […] — p. 33 · Read the full section →
The largest open question for OSCR: enhanced ACA subsidies lapsed 31 Dec 2025, and both renewal and non-renewal carry costs.
eAPTC expiry, the OBBBA eligibility cuts, and why a mid-2026 renewal would itself be disruptive.
The OBBBA enacted several provisions that may impact the number of enrollees in Health Insurance Marketplaces and, by extension, the size of our member population. These include ending the APTCs for individuals who enroll in plans via the SEP with income below 150% of the FPL, prohibiting automatic re-enrollment for tax year 2028, and eliminating APTC eligibility for some formerly covered individuals (such as refugees and other immigrant populations). While we expect these provisions to result in a reduction in the number of enrolled individuals in the Health Insurance Marketplace, we cannot predict with certainty the magnitude of the impact on our membership or our business. […] Even though the eAPTCs expired at the end of 2025, it is possible that they could be renewed, but the timing of such a decision, and the manner in which the eAPTCs could be renewed, is uncertain and could occur in 2026, which could cause potential disruption and uncertainty for the 2026 OEP. […] If the eAPTCs are renewed, it is possible that a SEP would be initiated which could alter member mix and enrollment levels (including by allowing individuals who enrolled with us during open enrollment to switch to a competitor’s plan), as well as shift consumer behavior.
p. 37 · Read in context →
Item 1A. Risk Factors — Failure to accurately estimate our incurred medical expenses or overall market morbidity […] — p. 39 · Read the full section →
The mechanism behind the FY2025 loss: premiums are set a year ahead on a forecast of market morbidity, and 2025 proved it wrong.
Pricing is set in advance on projected market morbidity — the assumption the year turned on.
We set our premiums in advance of each policy year based on competitive factors in each market in which we participate as well as projections of our future expenses and of the future morbidity of the Health Insurance Marketplace. As a result, the profitability of our insurance business depends, to a significant degree, on our ability to accurately estimate and effectively manage our medical expenses and administrative costs, as well as accurately estimate the future morbidity of the Health Insurance Marketplaces and estimate our risk adjustment transfer.
p. 39 · Read in context →
From the risk adjustment risk factor: the 2025 morbidity surprise, and the statutory capital it can consume.
For example, in the second and third quarters of 2025, the Company received third party reports indicating that the ACA average market risk scores (a measure of market morbidity) were significantly higher than the overall market expectation, which resulted in the Company significantly increasing its estimated risk adjustment transfer payable for such quarters. In the fourth quarter, the Company received third party reports indicating that overall market morbidity had stabilized, but that the Company had lower-than-anticipated relative risk scores, which resulted in the Company increasing its estimated risk adjustment transfer payable as of December 31, 2025. […] Furthermore, a significant change in our risk adjustment transfer estimates could require us to contribute additional capital to our Health Insurance Subsidiaries to meet statutory capital requirements. We may not be able to fund the increased capital contribution requirements with our available cash resources on a timely basis, or at all and may need to incur indebtedness or issue additional capital stock.
p. 43 · Read in context →
Item 7. MD&A — Recent Developments, Trends and Other Key Factors Impacting Performance — p. 99 · Read the full section →
Management's list of what moved 2025 and what is unresolved for 2026, starting with the subsidy that built the membership base.
The eAPTCs that grew the marketplace since 2021 expired at the end of 2025.
The enhanced Advanced Premium Tax Credits (“eAPTCs”) that were previously in place since 2021 contributed to increases in the population of the health insurance marketplaces established by the ACA and operated by the federal government, as well as other marketplaces operated by individual states (collectively, “Health Insurance Marketplaces”), as well as increases in our membership. […] These eAPTCs expired at the end of 2025 and if they are not renewed in 2026, coverage could become unaffordable to some individuals and thereby reduce overall participation in the Health Insurance Marketplaces
p. 99 · Read in context →
Item 7. MD&A — Critical Accounting Policies and Estimates: Benefits Payable — p. 106 · Read the full section →
The accounting that sets reported earnings for an insurer: completion factors drive the IBNR reserve, and a 0.25% error moves it ~$62m.
How the reserve is built and why completion factors are the estimate that matters.
Our development of the benefits payable estimate is a continuous process which we monitor and refine on a monthly basis as additional claims receipts and payment information becomes available. As more complete claims information becomes available, we adjust the amount of the estimates and include the changes in estimates in medical costs in the period in which the changes are identified. […] A completion factor is an actuarial estimate, based upon historical experience and analysis of current trends, of the percentage of incurred claims during a given period that have been adjudicated by us at the date of estimation. Completion factors are the most significant factors we use in developing our benefits payable estimates. […] If actual claims submission rates from providers (which can be influenced by a number of factors, including provider mix and electronic versus manual submissions) or our claim processing patterns are different than estimated, our reserve estimates may be significantly impacted.
p. 106 · Read in context →
Item 7. MD&A — Results of Operations — p. 111 · Read the full section →
The year in one page: total revenue +27% to $11.7bn, medical expense +37%, and $57m of operating profit becoming a $396m operating loss.
Management's attribution of the 5.7-point MLR increase and the offsetting SG&A leverage.
Medical expenses increased $2,686.4 million, or 37%, for the year ended December 31, 2025, compared to the year ended December 31, 2024, primarily due to increased membership and medical cost trend. MLR increased 5.7% year over year for the year ended December 31, 2025, primarily driven by an increase in average market morbidity that resulted in an increase in the net risk adjustment transfer accrual, as well as higher utilization that was not fully offset by risk adjustment. […] The SG&A Expense Ratio decreased 160 basis points year over year for the year ended December 31, 2025, primarily due to greater fixed cost leverage, lower exchange fee rates, and disciplined cost management, partially offset by the impact of higher risk adjustment as a percentage of premium.
p. 113 · Read in context →
Note 20. Risk Adjustment — p. 177 · Read the full section →
The rollforward that sizes the problem: the current-year risk adjustment payable rose from $1.56bn to $2.58bn in a single year.
Oscar Health, Inc. — FY2021 Annual Report (Form 10-K) — FY2021 (year ended December 31, 2021)
The first post-IPO full-year 10-K, and the clearest picture of what Oscar has since dismantled: three insurance markets and a SaaS ambition. · Open the full document →
Item 1. Business — Our Offerings — p. 7 · Read the full section →
Read against FY2025: three insurance markets and named +Oscar partners — two lines and every partner named here are now gone.
The 2021 three-market model and the +Oscar platform launch, including the Cigna and Health First arrangements.
In April 2021, we launched +Oscar, our tech-driven platform designed to help provider and payor clients drive improved efficiency, growth and superior engagement with their members and patients. Through +Oscar, we are monetizing our technology platform by offering business processes as a service to our clients, including Cigna + Oscar and Health First Health Plans. Our +Oscar deals generate fee-based compensation and can include risk-sharing components. We are also pursuing opportunities to offer our +Oscar platform as a software-as-a-service (“SaaS”) to enable future growth in this business. […] Today, we offer health plans in three insurance markets: Individual, Small Group, and Medicare Advantage across 607 counties and 22 states.
p. 7 · Read in context →
Item 1. Business — Our Growth Opportunities: Monetize our platform — p. 11 · Read the full section →
The platform-monetization case as originally put — risk-sharing, fees and SaaS — which FY2025 has narrowed to one product.
The 2021 pitch for selling the technology stack into 'multi-billion dollar industries'.
We have made significant investments to build a unique full stack technology platform that enables innovation in the global health care system. As a result, we believe we are well-positioned to monetize our platform through risk-sharing arrangements (where we take risk for provider claims on behalf of our members), through fee-based service arrangements (where we charge a fee per member or other fee structure) and through the development of a SaaS offering. […] Our platform today also has the ability to deliver solutions that represent multi-billion dollar industries, such as benefits management, claims processing, virtual care, and health care data and analytics. By leveraging our technology in areas such as machine learning, predictive analytics, and multimodal communication, we have built technology that is both member-first and helps lower costs. We believe that we have the ability to power these adjacent industries with our member engagement engine and full stack technology platform.
p. 11 · Read in context →
More annual reports
Oscar Health, Inc. — FY2024 Annual Report (Form 10-K) — FY2024 (year ended December 31, 2024) · 182 pages · The one profitable year: $25.4m of net income on an 81.7% MLR, filed weeks after the Cigna+Oscar Small Group exit took effect. · Open →
Oscar Health, Inc. — FY2023 Annual Report (Form 10-K) — FY2023 (year ended December 31, 2023) · 129 pages · The reset year: the exit from Medicare Advantage for plan year 2024 is documented here, the first 10-K with Mark Bertolini as CEO. · Open →
Oscar Health, Inc. — FY2022 Annual Report (Form 10-K) — FY2022 (year ended December 31, 2022) · 124 pages · The peak-loss year — $606.3m net loss — and the last 10-K written with Medicare Advantage, Small Group and +Oscar all still in the plan. · Open →
Source: S&P Capital IQ consensus via Xpressfeed · Generated 2026-07-28.
The consensus tape has been marked up hard: FY28 normalized EPS has gone from $1.08 to $2.21 over 180 days, and FY27 revenue from $14.1bn to $19.8bn. Most of that move landed between 180 and 90 days ago; over the last 30 days revenue has sat still and only EPS is still edging higher. The prints underneath read differently, with revenue below consensus four quarters running and EPS surprises swinging violently in both directions. The street has not followed the estimates: seven holds, no buys, and targets from $13 to $35.
FY28 EPS consensus has more than doubled in six months while revenue has been flat for 30 days
The revision is lopsided: FY28 EPS is up 105% over 180 days against 48% for revenue, and in the last 30 days revenue has gone sideways while EPS still ticks up. The feed carries no analyst count for the 180-day baseline, so part of that six-month gap may be a changing estimate set rather than broker-level revisions.
Currency: USD · Scale: money in millions, absolute · Point-in-time consensus; Δ90d is Now versus 90d.
| Metric | FY | 180d | 90d | 30d | Now | Δ90d |
|---|---|---|---|---|---|---|
| EPS (normalized) | FY2027 | $1.00 | $1.45 | $1.48 | $1.51 | +4.5% |
| EPS (normalized) | FY2028 | $1.07 | $1.88 | $2.18 | $2.21 | +17.1% |
| Revenue | FY2027 | $14.05bn | $19.56bn | $19.79bn | $19.78bn | +1.1% |
| Revenue | FY2028 | $15.06bn | $21.63bn | $22.24bn | $22.23bn | +2.7% |
Four straight revenue misses, but Q1 FY26 EPS landed 88% above consensus
Revenue has come in below consensus in each of the last four quarters, the largest a 10% shortfall in Q4 FY25. Normalized EPS is the opposite: the two most recent prints missed by 35% and then beat by 88%, so the quarterly EPS line carries little predictive value.
Current sequences by metric: Revenue: 4 consecutive misses; EPS (normalized): 1 consecutive beat.
Currency: USD · Scale: money in millions, absolute · Consensus is captured before each actual first became effective.
| Quarter | Metric | Consensus | Actual | Surprise | Outcome |
|---|---|---|---|---|---|
| Q1 FY2026 | Revenue | $4.92bn | $4.65bn | -5.5% | Miss |
| Q1 FY2026 | EPS (normalized) | $1.10 | $2.07 | +88.2% | Beat |
| Q4 FY2025 | Revenue | $3.12bn | $2.81bn | -10.2% | Miss |
| Q4 FY2025 | EPS (normalized) | -$0.92 | -$1.24 | -34.6% | Miss |
| Q3 FY2025 | Revenue | $3.08bn | $2.99bn | -3.1% | Miss |
| Q3 FY2025 | EPS (normalized) | -$0.58 | -$0.53 | +8.7% | Beat |
| Q2 FY2025 | Revenue | $2.92bn | $2.86bn | -1.9% | Miss |
| Q2 FY2025 | EPS (normalized) | -$0.84 | -$0.89 | -6.5% | Miss |
| Q1 FY2025 | Revenue | $2.87bn | $3.05bn | +6.3% | Beat |
| Q1 FY2025 | EPS (normalized) | $0.81 | $0.92 | +13.9% | Beat |
| Q4 FY2024 | Revenue | $2.47bn | $2.39bn | -3.2% | Miss |
| Q4 FY2024 | EPS (normalized) | -$0.58 | -$0.62 | -6.5% | Miss |
| Q3 FY2024 | Revenue | $2.35bn | $2.42bn | +3.3% | Beat |
| Q3 FY2024 | EPS (normalized) | -$0.18 | -$0.22 | -25.0% | Miss |
| Q2 FY2024 | Revenue | $2.17bn | $2.22bn | +2.2% | Beat |
| Q2 FY2024 | EPS (normalized) | $0.15 | $0.20 | +29.0% | Beat |
Forward estimates
Currency: USD · Scale: money in millions, absolute · YoY uses the prior fiscal year from the feed; analyst count and range use the first displayed period.
| Metric | FY2025A | FY2026E | FY2027E | FY2028E | YoY | Analysts | Low / high |
|---|---|---|---|---|---|---|---|
| Revenue | $12.02bn | $18.54bn | $19.78bn | $22.23bn | — | 9 | $11.93bn / $12.10bn |
| EBITDA | -$189.83m | $525.82m | $725.93m | $1.01bn | — | 7 | -$232.62m / -$162.00m |
| Gross margin | 15.0% | 18.3% | 18.7% | 19.5% | — | — | — |
| EPS (normalized) | -$1.29 | $1.10 | $1.51 | $2.21 | — | 8 | -$1.42 / -$1.19 |
Eight analysts put FY27 EBITDA anywhere from $486m to $1,109m
FY27 EBITDA is the widest economically material line, with a spread worth 86% of the mean across eight analysts. Even FY26, with one quarter already reported, still carries a $0.63 to $1.49 normalized EPS range across ten analysts.
Currency: USD · Scale: money in millions, absolute · Spread/mean is absolute high-low divided by absolute mean.
| Metric | Period | Mean | Low–high | Spread/mean | Analysts |
|---|---|---|---|---|---|
| EBITDA | FY2027E | $725.93m | $485.75m–$1.11bn | 85.8% | 8 |
| EPS (normalized) | FY2026E | $1.10 | $0.63–$1.49 | 78.3% | 10 |
| Revenue | FY2027E | $19.78bn | $15.22bn–$21.74bn | 33.0% | 9 |
| Revenue | FY2028E | $22.23bn | $17.56bn–$23.89bn | 28.5% | 5 |
No buys against seven holds, and targets spanning $13 to $35
Eleven ratings carry no buys and no sells: seven holds, three outperform, one underperform, for a consensus score of 2.82. The ten targets run $13 to $35 against a $24.20 mean and a $21 median, so the mean sits well above the median.
Currency: USD · Scale: money in millions, absolute · Analyst counts shown explicitly.
| Street view | Reading | Analysts |
|---|---|---|
| Recommendation mix | Buy 0, Outperform 3, Hold 7, Underperform 1, Sell 0 | 11 |
| Consensus score | 2.82 | 11 |
| Target price | mean $24.20; median $21.00; high $35.00; low $13.00 | 10 |
FY29 rests on one analyst; FY28 on five
FY29 carries a single analyst on two lines only, so the $2.62 EPS and $1,189m EBITDA are one broker's model rather than a consensus. FY28 thins to five analysts on revenue and six on EPS, meaning the FY27-to-FY28 step is drawn by a smaller panel than the FY26 and FY27 columns.
Visible Alpha broker models via S&P Xpressfeed · 10 brokers · 303 line items · freshest revision 2026-07-14.
FY-2026 is the margin inflection: MLR 86.6% to 82.9%, underwriting margin 13.3% to 17.0%
Consensus keeps grinding the loss ratio and cost ratio lower through FY-2028, but at a fraction of the FY-2026 step - the re-rating in these models is a one-year repricing event, not a trend. The combined ratio row rests on three brokers; the loss ratio has ten.
| Line | FY-2025A | FY-2026E | FY-2027E | FY-2028E | YoY | Brokers |
|---|---|---|---|---|---|---|
| Loss ratio | — | — | — | — | — | — |
| Medical loss ratio(%) | 86.6% | 82.9% | 82.3% | 81.7% | -3.7pt | 10 |
| Underwriting | — | — | — | — | — | — |
| Underwriting profit | $1.57bn | $3.09bn | $3.41bn | $3.85bn | +96.4% | 7 |
| Underwriting margin(%) | 13.3% | 17.0% | 17.6% | 18.0% | +3.7pt | 7 |
| InsuranceCo combined ratio(%) | 104.6% | 99.0% | 98.1% | 97.2% | -5.7pt | 3 |
| Costs | — | — | — | — | — | — |
| SG&A / Sales(%) | 17.5% | 16.2% | 16.0% | 15.7% | -1.2pt | 8 |
| Profit | — | — | — | — | — | — |
| Adjusted EBITDA | $-182.48m | $463.07m | $660.38m | $903.43m | +353.8% | 10 |
| Income / (loss) from operations | $-304.23m | $349.76m | $530.51m | $772.69m | +215.0% | 10 |
Enrollment stops growing after FY-2026 - PMPM of $673 rising to $789 by FY-2028 carries the top line
Individual & small group is effectively the whole company here: the total and segment lines barely differ. Mean and median membership diverge from FY-2027 onward, so at least one broker models a materially smaller book after the ACA subsidy reset.
| Line | FY-2025A | FY-2026E | FY-2027E | FY-2028E | YoY | Brokers |
|---|---|---|---|---|---|---|
| Members | — | — | — | — | — | — |
| Total membership(K#) | 2.08m Number | 2.75m Number | 2.80m Number | 3.02m Number | +32.4% | 10 |
| Total membership - Individual & small group(K#) | 2.08m Number | 2.74m Number | 2.79m Number | 2.93m Number | +31.7% | 10 |
| Price | — | — | — | — | — | — |
| Per member per month (PMPM)($) | $565.9 | $673.1 | $736.6 | $789.2 | +18.9% | 9 |
| Per Member Per Month (PMPM) - Individual & small group($) | $555.1 | $597.4 | $653.0 | $682.8 | +7.6% | 7 |
| Premium | — | — | — | — | — | — |
| Direct and assumed premiums | $14.11bn | $22.70bn | $24.86bn | $27.88bn | +60.9% | 9 |
| Premiums earned | $11.79bn | $18.29bn | $19.66bn | $21.86bn | +55.1% | 10 |
Modeled profit is front-loaded: 1QFY-2027 MLR of 70.3% against 92.8% in 4QFY-2026
Membership peaks in 1QFY-2026 and attrites through the year, so the worst loss ratio lands on the smallest base. Brokers then model an even lower first-quarter loss ratio in FY-2027, which is the single largest swing factor inside the FY-2027 annual numbers.
| Line | 3QFY-2025A | 4QFY-2025A | 1QFY-2026A | 2QFY-2026A | 3QFY-2026E | 4QFY-2026E | 1QFY-2027E | 2QFY-2027E | Brokers |
|---|---|---|---|---|---|---|---|---|---|
| Medical loss ratio(%) | 89.0% | 91.8% | 76.3% | 82.1% | 86.5% | 92.8% | 70.3% | 80.4% | 10 |
| Adjusted EBITDA | $-119.49m | $-209.80m | $468.12m | $171.12m | $-49.92m | $-385.20m | $790.24m | $278.12m | 10 |
| Underwriting profit | $325.92m | $250.32m | $1.12bn | $824.18m | $605.97m | $310.24m | $1.44bn | $978.00m | 7 |
| Premiums earned | $3.03bn | $3.07bn | $4.87bn | $4.67bn | $4.58bn | $4.46bn | $4.90bn | $4.98bn | 10 |
| Total membership(K#) | 2.03m Number | 2.08m Number | 3.12m Number | 2.93m Number | 2.82m Number | 2.72m Number | 2.95m Number | 2.88m Number | 10 |
The FY-2027 dispute is the size of the book and how much margin it carries
The loss-ratio spread alone is worth more than the entire modeled EBITDA at the low end, which is why the profit range is so wide. Free cash flow disagreement is wider still and spans zero, because cash conversion depends on whether the book keeps growing.
| Line | Period | Median | Q1–Q3 | Min–max | Brokers |
|---|---|---|---|---|---|
| Adjusted EBITDA | FY-2027E | $668.66m | $619.72m–$740.72m | $151.09m–$1.11bn | 10 |
| Medical loss ratio(%) | FY-2027E | 82.5% | 81.7%–82.7% | 80.0%–84.7% | 10 |
| Total membership(K#) | FY-2027E | 2.93m Number | 2.65m Number–2.99m Number | 2.29m Number–3.09m Number | 10 |
| Per member per month (PMPM)($) | FY-2027E | $733.7 | $708.3–$742.8 | $680.8–$825.6 | 9 |
| Free cash flow (FCF) | FY-2027E | $1.07bn | $422.88m–$1.14bn | $-249.69m–$2.05bn | 9 |
Everything outside Individual & Small Group is one or two brokers, last revised in 2024
The Medicare Advantage membership and PMPM lines carry one to two brokers with revision dates in 2024, and the Cigna + Oscar lines are a single broker. Read them as one analyst's stub, not as a view of the street. Segment insight in this feed is effectively limited to the Individual & Small Group book.
Headline P&L consensus, momentum and beat/miss live in the CapIQ tab.
Source: S&P Capital IQ transcripts via Xpressfeed · latest indexed call 2026-05-06 · generated 2026-07-28.
Latest call digest
Oscar Health, Inc., Q1 2026 Earnings Call, May 06, 2026 · 2026-05-06T12:00:00
Q1 2026 — May 6, 2026. Prepared remarks were a clean beat: revenue of $4.6 billion (+53%), MLR of 70.5% (490 bps better year-over-year), an SG&A ratio of 15.2%, earnings from operations of $704 million and net income of approximately $679 million on 3.2 million members (+56%). Full-year guidance was reaffirmed in full — revenue of $18.7 billion to $19 billion, MLR of 82.4% to 83.4%, SG&A of 15.8% to 16.3% and earnings from operations of $250 million to $450 million — with management saying results are ahead of plan and that Oscar is positioned to meet or exceed the guide. Mark Bertolini used the prepared section mainly for strategy: the Lucie Health Marketplace, ICHRA X, and an Investor Day on September 16.
The Q&A went somewhere else. Roughly half the questions were about one line item: risk adjustment. Oscar accrued risk adjustment at about 24% of premium in the quarter against a full-year guide of approximately 20%, and Andrew Mok (Barclays) and Jonathan Yong (UBS) both pressed on the gap. Richard Blackley's explanation is mechanical — seasonally low first-quarter claims suppress the denominator, and a heavier bronze mix pushes deductible-driven claims later in the year — with normalization expected as members engage. Asked what could still move 2026 EBITDA, Bertolini answered with the Wakely reports and risk adjustment, noting the accrual was 11% at this point last year versus 24.5% now.
What management chose not to book is the more interesting disclosure. Prior period development was $68 million net favorable, but that nets $85 million of adverse development on a couple of 2025 states against $150 million of favorable claims run-out; other states with positive development were left unrecognized pending the final report. Reserves remain set on the pricing-era market morbidity assumptions, so the favorability visible in the new Wakely report is described as a potential tailwind rather than something already in the numbers. Utilization was characterized as unremarkable, and the paid-membership walk (3.4 million to 3.2 million to roughly 3 million on April 1) tracked plan, with most of the drop-off members who never made a payment. The one question management declined to quantify was Lucie's financial contribution.
Participant coverage from the latest call.
| Group | Participants | Count |
|---|---|---|
| Management | Operator; Chris Potochar — Vice President of Treasury & Investor Relations, Oscar Health, Inc.; Mark Bertolini — CEO & Director, Oscar Health, Inc.; Richard Blackley — Chief Financial Officer, Oscar Health, Inc. | 4 |
| Analysts | Jessica Tassan — Director & Senior Research Analyst, Piper Sandler & Co., Research Division; John Ransom — MD of Equity Research & Director of Healthcare Research, Raymond James & Associates, Inc., Research Division; Andrew Mok — Director, Barclays Bank PLC, Research Division; Samuel Becker — Research Analyst, Goldman Sachs Group, Inc., Research Division; Jonathan Yong — Analyst, UBS Investment Bank, Research Division; Olivia Miles — Research Analyst, Robert W. Baird & Co. Incorporated, Research Division; Raj Kumar — Research Analyst, Stephens Inc., Research Division; Craig Jones — Research Analyst, BofA Securities, Research Division; Dillon Nissan — Research Analyst, Wolfe Research, LLC | 9 |
Curated latest-call exchanges; one row per analyst topic.
| Analyst | Firm | Topic | What changed in Q&A |
|---|---|---|---|
| Andrew Mok | Barclays Bank PLC, Research Division | Risk adjustment accrual vs. full-year guide | Pressed on why risk adjustment transfer is tracking around 24% of premium while the full-year expectation stays at approximately 20%. Blackley attributed it to seasonally low first-quarter claims mechanically lifting the accrual and to a higher share of new members in bronze plans, with normalization expected as deductibles are met. |
| Jonathan Yong | UBS Investment Bank, Research Division | Whether the accrual included 2025 cleanup | Asked directly whether any 2025 sweep sat inside the number. The answer surfaced the quarter's most specific disclosure: about $85 million of adverse development from a couple of states on the last 2025 Wakely report was recognized, other states with positive development were not, and $150 million of favorable claims run-out produced the $68 million net favorable PPD. |
| Jessica Tassan | Piper Sandler & Co., Research Division | Churned members and market morbidity | Asked whether the roughly 200,000 members who fell off between the first quarter and April 1 pulled utilization forward, and whether Oscar agrees with Wakely's market morbidity range. Blackley said the bulk never made a payment and that claims are not paid once a member is delinquent; on Wakely he would say only in line to favorable, this early. |
| Samuel Becker | Goldman Sachs Group, Inc., Research Division | Swing factors for 2026 EBITDA | Asked what could still materially shift the 2026 view. Bertolini named the Wakely numbers and risk adjustment, and framed the year-over-year comparison as 11% risk adjustment at this point last year against 24.5% now. His answer trails off in the transcript with no follow-up. |
| Olivia Miles | Robert W. Baird & Co. Incorporated, Research Division | Lucie Health Marketplace economics | Asked whether revenue or EBIT contribution from Lucie is in the 2026 guide, and for a revenue basis or long-term target. No figures were given: Bertolini described the model and deferred detail to September, and Blackley said standing-up costs are in guidance with a modest effect this year. |
| John Ransom | Raymond James & Associates, Inc., Research Division | SG&A trajectory and April membership | Asked why the SG&A ratio would rise if revenue gets a lift from lower risk adjustment. Blackley said SG&A dollars grew 46% against 53% revenue growth, called the first quarter the likely low point for the year, and guided to sideways-to-slightly-up with a fourth-quarter uptick for open enrollment. Confirmed roughly 3 million members as of April 1. |
| Craig Jones | BofA Securities, Research Division | Bronze mix and the risk adjustment payable | Asked how a mix shift toward bronze affects risk adjustment year-over-year. Blackley argued the formula's coefficients are designed to be roughly metal-neutral, and that Oscar's transfer is driven more by overall utilization levels and market and product selection than by metal mix. |
| Raj Kumar | Stephens Inc., Research Division | Effectuation rates and competitor exits | Asked about market-level effectuation and how a competitor exit flows into 2027 pricing. Blackley said effectuation has run as expected to modestly favorable and consistent with Wakely's assumptions; Bertolini credited broker preparation and product mapping done ahead of the subsidy sunset for the share gains. |
| Dillon Nissan | Wolfe Research, LLC | Economics in newer, smaller states | Asked for early reads on Arizona, North Carolina and New Jersey. Bertolini declined on the grounds that there are not yet enough claims to differentiate; Blackley added that growth in newer markets looks strong but that it is too early to get ahead of themselves. |
Theme tracker
Themes are curator-classified across supplied calls.
| Theme | Status | Quarters mentioned | Read-through |
|---|---|---|---|
| Risk adjustment estimation and market morbidity | persisted | Q2 2023, Q3 2023, Q4 2023, Q1 2024, Q2 2024, Q3 2024, Q4 2024, Q1 2025, Q2 2025, Q3 2025, Q4 2025, Q1 2026 | Present in every call in the set, but its character changed. Through 2023 and 2024 it was a modelling topic that mostly produced small true-ups; from the fourth quarter of 2024 it became the dominant earnings variable, with successive increases to the risk adjustment payable in 2025 and, in the latest call, an accrual running above the full-year guide. Management has consistently called it the hardest estimate it makes. |
| AI and technology-driven administrative leverage | persisted | Q2 2023, Q3 2023, Q4 2023, Q1 2024, Q2 2024, Q3 2024, Q4 2024, Q1 2025, Q2 2025, Q3 2025, Q4 2025, Q1 2026 | The one line where the story has run in a straight line. The SG&A ratio is cited as improving every year across the set, and analysts have repeatedly treated it as the most credible part of the model. Notably, it is also the topic that draws the fewest sceptical follow-ups. |
| ICHRA as a growth vector beyond the ACA | persisted | Q2 2023, Q3 2023, Q1 2024, Q2 2024, Q3 2024, Q4 2024, Q1 2025, Q2 2025, Q3 2025, Q4 2025, Q1 2026 | Discussed on nearly every call for three years, and still not quantified. Management said in the fourth quarter of 2025 that it is not giving out ICHRA numbers by segment because they are not meaningful enough to move the dial. The framing has moved from a carrier product to a distribution and platform business. |
| Enhanced premium tax credit expiry and market contraction | persisted | Q4 2023, Q2 2024, Q3 2024, Q1 2025, Q2 2025, Q3 2025, Q4 2025, Q1 2026 | First raised as an analyst question, then adopted by management as the organizing assumption for pricing. The 20% to 30% market contraction estimate introduced in the third quarter of 2025 has been carried forward each quarter since; the latest call says contraction is tracking in line to favorable against it. |
| Medicaid redeterminations and special enrollment membership | dropped | Q2 2023, Q3 2023, Q4 2023, Q1 2024, Q2 2024, Q3 2024, Q4 2024, Q1 2025, Q2 2025, Q3 2025, Q4 2025 | A central topic for eleven consecutive calls — it drove both the 2024 growth story and the 2025 morbidity problem — and absent from the Q1 2026 call entirely. The continuous monthly special enrollment period ended in September 2025, and membership discussion has shifted to grace-period non-payment. The disappearance looks structural rather than evasive. |
| +Oscar and Campaign Builder as an external technology business | dropped | Q2 2023, Q3 2023, Q4 2023, Q1 2024, Q2 2024 | One of four stated strategic pillars in 2023, with named client wins and a lives-served count. It has not appeared in management's prepared remarks since the second quarter of 2024, and no call in the set explains the de-emphasis. Worth noting given the current pitch for Lucie rests on a similar platform-and-technology argument. |
| 2027 long-term targets (20% revenue CAGR, 5% operating margin) | dropped | Q2 2024, Q3 2024, Q4 2024, Q1 2025, Q2 2025, Q3 2025 | Repeated in prepared remarks or defended under questioning on six consecutive calls, including the second quarter of 2025 when Bertolini said 5% remains the target. Neither the fourth quarter 2025 nor the first quarter 2026 call restates it, and no analyst asked. Management now points to a September 16 Investor Day for the long-term plan. |
| Carrier-agnostic consumer marketplace (Lucie, ICHRA X) | emerged | Q2 2025, Q1 2026 | The building blocks were bought in the second quarter of 2025 — a brokerage, the INSXCloud direct enrollment platform and healthinsurance.org — and described then as not meaningful to near-term results. The first quarter of 2026 is the first call where they are presented as a named, launched business with an unregulated, higher-margin economic pitch. No revenue or margin figures have been attached to it yet. |
Guidance ledger
Quotes, calls, and speakers are source-verified; outcomes are curator-classified.
| Verbatim guidance | Call | Speaker | Curator outcome | Outcome note |
|---|---|---|---|---|
| “We continue to expect to achieve total company adjusted EBITDA profitability this year and are raising our estimate to a range of $160 million to $210 million.” | Oscar Health, Inc., Q2 2024 Earnings Call, Aug 07, 2024 · 2024-08-07T12:00:00 | Richard Blackley | kept | The Q4 2024 call reported full year 2024 adjusted EBITDA of $199 million, inside the range. |
| “We are raising our guidance for total revenue by another $200 million to a range of $9.2 billion to $9.3 billion, reflecting higher membership, driven by SEP member additions and more favorable lapse rates as compared to our expectations.” | Oscar Health, Inc., Q3 2024 Earnings Call, Nov 07, 2024 · 2024-11-07T13:00:00 | Richard Blackley | kept | The Q4 2024 call reported full year total revenue of $9.2 billion, at the low end of the range. |
| “We expect our medical loss ratio to be in the range of 80.7% to 81.7%, representing a 50 basis point year-over-year improvement at the midpoint.” | Oscar Health, Inc., Q4 2024 Earnings Call, Feb 04, 2025 · 2025-02-04T22:00:00 | Richard Blackley | missed | The Q4 2025 call reported a full year 2025 MLR of 87.4%, well above the range. Management attributed the gap primarily to higher market morbidity and the resulting risk adjustment payable. |
| “We expect earnings from operations to be in the range of $225 million to $275 million, representing a significant $193 million improvement year-over-year at the midpoint.” | Oscar Health, Inc., Q4 2024 Earnings Call, Feb 04, 2025 · 2025-02-04T22:00:00 | Richard Blackley | missed | The Q4 2025 call reported a full year 2025 loss from operations of approximately $396 million against guidance for a $225 million to $275 million profit. The guide was cut to a loss range in July 2025. |
| “We expect a loss from operations in the range of $200 million to $300 million and an adjusted EBITDA loss of approximately $120 million less than the loss from operations.” | Oscar Health, Inc., Q2 2025 Earnings Call, Aug 06, 2025 · 2025-08-06T12:00:00 | Richard Blackley | missed | Reaffirmed on the Q3 2025 call, then exceeded: the Q4 2025 call reported a full year loss from operations of approximately $396 million and an adjusted EBITDA loss of approximately $280 million. |
| “We expect these actions will eliminate approximately $60 million in administrative costs for 2026.” | Oscar Health, Inc., Q2 2025 Earnings Call, Aug 06, 2025 · 2025-08-06T12:00:00 | Mark Bertolini | unknown | Repeated on the Q3 2025 call. No subsequent call in the set quantifies realization against the $60 million figure, though the 2025 SG&A ratio improved 160 basis points year-over-year. |
| “We continue to expect a full year MLR in the range of 86.0% to 87.0%.” | Oscar Health, Inc., Q3 2025 Earnings Call, Nov 06, 2025 · 2025-11-06T13:00:00 | Richard Blackley | missed | Full year 2025 MLR came in at 87.4% per the Q4 2025 call, above the top of the range, driven by a $275 million fourth quarter risk adjustment true-up. |
| “For 2026, we expect risk adjustment as a percentage of direct premiums to be approximately 20% based on our updated membership mix and 2025 risk adjustment experience.” | Oscar Health, Inc., Q4 2025 Earnings Call, Feb 10, 2026 · 2026-02-10T13:00:00 | Richard Blackley | pending | The Q1 2026 accrual ran around 24% of premium, which management attributes to seasonally low claims and expects to converge on 20% over the year. This is the single most load-bearing assumption in the 2026 guide. |
| “We expect earnings from operations to be in the range of $250 million to $450 million, a significant improvement of nearly $750 million year-over-year, implying an operating margin of approximately 1.9% at the midpoint.” | Oscar Health, Inc., Q4 2025 Earnings Call, Feb 10, 2026 · 2026-02-10T13:00:00 | Richard Blackley | pending | Reaffirmed on the Q1 2026 call, which reported $704 million of earnings from operations in the first quarter alone under the company's stated MLR seasonality. |
| “Total revenues are still expected to be in the range of $18.7 billion to $19 billion in 2026.” | Oscar Health, Inc., Q1 2026 Earnings Call, May 06, 2026 · 2026-05-06T12:00:00 | Richard Blackley | pending | Unchanged from the initial 2026 guide given on the Q4 2025 call. First quarter revenue was $4.6 billion. |
| “MLR remains in the range of 82.4% to 83.4%, with MLR lowest in the first quarter and highest in the fourth quarter.” | Oscar Health, Inc., Q1 2026 Earnings Call, May 06, 2026 · 2026-05-06T12:00:00 | Richard Blackley | pending | First quarter MLR was 70.5%, consistent with the stated seasonality. The full-year range assumes claims and risk adjustment normalize over the balance of the year. |
Q&A pressure map
Question counts and firms are curator tallies; analyst coverage shown above.
| Topic | Questions | Firms | Pressure / response |
|---|---|---|---|
| Risk adjustment accrual and market morbidity | 7 | Piper Sandler & Co., Research Division, Barclays Bank PLC, Research Division, Goldman Sachs Group, Inc., Research Division, UBS Investment Bank, Research Division, Robert W. Baird & Co. Incorporated, Research Division, BofA Securities, Research Division | Counts are for the Q1 2026 call, where this topic took most of the Q&A. Six firms circled the same gap from different angles: the quarter accrued near 24% of premium against a 20% full-year guide. Management's answers were consistent and mechanical, and each disclosed something the prepared remarks did not — the bronze-mix seasonality, the $85 million of unrecognized state-level offsets, and the decision to hold reserves at pricing-era morbidity assumptions. The topic has led the Q&A on every call since Q2 2025. |
| Membership churn, effectuation and paid members | 3 | Piper Sandler & Co., Research Division, Raymond James & Associates, Inc., Research Division, Stephens Inc., Research Division | Q1 2026 counts. Analysts are testing whether the 3.4 million to 3 million walk holds and whether the members who left were costly on the way out. Answers were specific and matched what was guided on the prior call. This line of questioning has run for four consecutive quarters, since the subsidy sunset became the base case. |
| New-market and competitor-exit economics | 2 | Stephens Inc., Research Division, Wolfe Research, LLC | Q1 2026 counts. Both questions asked for early state-level or cohort-level reads on newly acquired members; both were answered with a claims-maturity argument rather than data. Reasonable this early in a policy year, but it means the quality of the 56% membership growth is still unverified externally. |
| Lucie Health Marketplace economics | 1 | Robert W. Baird & Co. Incorporated, Research Division | Q1 2026 count. The question asked for revenue or EBIT contribution in 2026, the scaling path, and any long-term revenue basis or targets. The answer covered the strategic rationale and network economics and stated that costs are inside guidance with a modest effect, but none of the three quantitative items asked for were addressed; they were deferred to the September Investor Day. Worth flagging conservatively, since Lucie was the main new item in the prepared remarks. |
| SG&A trajectory and operating leverage | 1 | Raymond James & Associates, Inc., Research Division | Q1 2026 count. A single question, answered directly with the SG&A dollar growth rate against revenue growth and a clear statement that the first quarter is likely the low point for the year. The historic pattern holds: this is the one topic where management volunteers more than it is asked for. |
| Utilization and seasonal cost drivers | 1 | UBS Investment Bank, Research Division | Q1 2026 count. Asked whether flu or weather drove the beat. Management said neither was abnormal, that experience has been better than anticipated, and — importantly — that not all of that favorability has been booked. |
Language shifts
Only language evidence verified against the referenced component is shown.
| Observation | Verbatim evidence | Call ID | Component |
|---|---|---|---|
| Conservatism is being stated explicitly in prepared remarks rather than left to the Q&A. The phrasing echoes the reserving language used in 2023, which had largely disappeared from prepared commentary across 2024 while results were running ahead. | “We took a cautious approach to risk adjustment in the first quarter.” | 1993764732 | 2 |
| Management is now describing asymmetric recognition on the record: adverse state-level development taken in the quarter, favorable development held back. That is a deliberate framing of reserve conservatism as a stored tailwind, and it is new language in this set. | “We chose not to recognize those and wait for the final report.” | 1993764732 | 28 |
| The tone on medical cost trend has moved from problem-description to non-event. A year earlier the same executive opened prepared remarks by naming a market-wide morbidity shift; here utilization is characterized as notable for being unremarkable. | “I think the most insightful thing about utilization patterns is the lack of interesting utilization patterns.” | 1993764732 | 32 |
| Confidence expressed in mid-2025 about morbidity having stabilized preceded further deterioration. The Q3 2025 call recorded a $130 million increase to the risk adjustment payable and the Q4 2025 call a further $275 million true-up. Useful calibration for how much weight to place on similar in-line-to-favorable language now. | “But we don't see anything in our statistics through the second quarter that caused us to think that there's another leg that's going to drop in terms of market morbidity.” | 1954169326 | 52 |
| Hedging vocabulary entered the Q4 2025 call around member behavior after the subsidy sunset, in place of the firmer retention language used in prior years. The Q1 2026 call retires it: payment rates are described as consistent year-over-year and modestly favorable to plan. | “So we're not – we're hedging our bets on the level of disenrollment that will occur as a result.” | 1977980145 | 31 |
| Guidance language stepped up from reaffirming to a stated bias to the upside, a formulation that does not appear in the 2025 calls in this set. It sits somewhat awkwardly beside the decision to hold reserves at pricing-era morbidity assumptions. | “Our strong results in the first quarter are ahead of plan, and we are well positioned to meet or exceed our current guidance.” | 1993764732 | 2 |
Three years of calls point the debate at one number. Operating leverage has compounded without interruption and the underwriting commentary has been broadly reliable; what has repeatedly broken the guide is the estimate of other carriers' books. The 2026 setup differs in that the conservatism now sits in disclosed, unrecognized favorability rather than in tone, which makes the June Wakely report the checkpoint that matters more than any operating metric.
Competitors describe Oscar Health, Inc.'s market in their own filings and calls. These verified passages and visual pages show where their strategies meet, using source documents preserved in Sources.
Centene Corporation (Ambetter Health) (CNC)
The largest carrier in the ACA Individual Marketplace and the peer whose book sits closest to Oscar's in both size and shape — 3.58 million members at the end of Q1 2026 against Oscar's 3.2 million, in a 29-state footprint that overlaps Oscar's almost everywhere. Only the Commercial/Marketplace discussion is used here; Centene's Medicaid and Medicare (PDP and MA) segments, which are the bulk of its revenue, are outside the comparison. Centene also built the industry data infrastructure — the interim Wakely market report — that both companies now price and reserve against, and its 10-K carries the ICHRA thesis Oscar has made central to its own strategy.
Centene's read of the first post-subsidy plan year, from the April 2026 call, and the origin of the interim Wakely report that every carrier in this tab now cites. Two claims sit inside it. The market-level one — contraction smaller than expected, healthier members staying, a silver-to-bronze migration — is corroborated by Elevance and Molina elsewhere in this tab and is the same directional read Oscar gave. The company-level one is contested by construction: Centene argues its retained silver block is more acute than the market and should therefore draw a risk-adjustment receivable. Risk adjustment is a zero-sum transfer, so a receivable claimed by the largest carrier in a state has to be funded by the other carriers in that state. Centene had not booked the full amount as of this call.
Sarah London (Chief Executive Officer): After last year's unexpected volatility, Centene committed to finding ways to create additional and earlier visibility into this market to support long-term stability. Last fall, we reached out to many of our peers, all of whom were receptive to submitting earlier data on membership demographics. Wakely, the independent actuarial firm that calculates interim risk transfer estimates for the market throughout the year, agreed to aggregate and publish that data at the end of March. As a result of that collaboration, the industry has more visibility than it has ever had at this time of the year about overall market dynamics. […] First, the overall market contracted as expected in a post-APTCs environment. That said, market-by-market membership loss was in almost every market less than we expected, which suggests that more healthy members stayed in the market in aggregate and that our pricing was appropriate relative to the overall market morbidity. Second, the Wakely data confirmed a meaningful market-wide shift from Silver members into Bronze and to a lesser degree, Gold, consistent with our expectations and with a directional shift in our own metal distribution. Finally, and perhaps most importantly, this data, when combined with our final Q1 paid membership and a full quarter's worth of claims experience, strongly supports the view that Ambetter retains Silver membership with higher acuity relative to the market and that this membership will ultimately receive a meaningful risk adjustment offset.
p. 2 · Read in context →
Elevance Health, Inc. (Anthem Blue Cross / Wellpoint) (ELV)
The scaled Blues competitor that stayed in the individual market and expanded into it. Elevance sells on-exchange in nearly all of its Anthem service areas and pushed into Florida, Maryland and Texas in 2025 under the Simply Healthcare and Wellpoint brands — three states central to Oscar's footprint. Only the Individual/ACA discussion is used here; Elevance's employer group, Medicaid, Medicare and Carelon services businesses are outside the comparison, and the company does not break out individual ACA membership or margin separately, so the exhibits are management's qualitative reads plus the sizing of quarterly outperformance.
Elevance's stated exchange footprint from its FY2025 Form 10-K. The commercially relevant sentence is the second paragraph: while Aetna was exiting and Cigna was shrinking, Elevance added Florida, Maryland and Texas service areas in 2025 under non-Blue brands. Florida and Texas are the two largest states in the federal Marketplace and core Oscar geographies. The filing gives no membership or premium figure for the Individual book, so this establishes direction and geography, not scale — Elevance's disclosed medical membership of 44.9 million is overwhelmingly employer group, Medicaid and Medicare.
In the Individual markets, we offer on-exchange products through state- or federally-facilitated marketplaces (the “Public Exchange”) in compliance with the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, as amended (collectively, the “ACA”) and off-exchange products. Federal subsidies are available for certain members, subject to eligibility, who purchase Public Exchange products.
We continue to participate in the Public Exchange in nearly all of our Anthem Blue Cross and Anthem Blue Cross and Blue Shield service areas. In 2025, we expanded our operations into select service areas in Florida, Maryland, and Texas through our Simply Healthcare and Wellpoint brands. Going forward, we expect the Public Exchange to be influenced by policy and regulatory changes, particularly around federal subsidies, compliance requirements and market stability.
p. 8 · Read in context →
Answering an analyst who asked where Elevance sits versus the industry on the new Wakely data. This is a second independent carrier confirming the silver-to-bronze migration Centene described, and adding a caveat worth carrying: the March report does not capture retroactive cancellations, non-payment or cohort maturation. Those are exactly the effectuation dynamics that determine whether first-quarter membership counts hold — relevant to reading Oscar's own 3.2 million enrolled versus roughly 3.0 million paid at the start of Q2.
Mark Kaye (Chief Financial Officer): The early Wakely report has been a helpful input because it provides visibility into market size, metal mix and enrollment patterns. The report supports our view of a greater shift towards bronze and a greater share of new sales, which has implications for relative risk in the market. I would caution it's still early; the report does not fully capture retro cancellations, nonpayment behavior or maturing cohorts. […] We feel comfortable with our pricing and positioning for sustainability in the ACA market this year. We are seeing a much more balanced bronze-silver mix this year based on new sales.
p. 12 · Read in context →
UnitedHealth Group (UnitedHealthcare exchange business) (UNH)
The one large national carrier that repriced across the board and stayed in every state it served, rather than exiting. Its posture matters to Oscar twice over: as the pricing benchmark in overlapping states, and because UnitedHealthcare voluntarily pledged to rebate its 2026 ACA profits to customers — a political marker on how much margin the individual market is expected to bear while subsidies are contested. Only the UnitedHealthcare exchange discussion is used here; Medicare Advantage, Medicaid, employer group and the entire Optum business are outside the comparison.
UnitedHealthcare's stated 2026 exchange posture: reprice nearly every state, keep the full state footprint, and hand back the resulting profit. The rebate pledge is the item with implications beyond United's own P&L — the largest US health insurer publicly conceding that earning a margin on ACA plans is politically untenable in a year when subsidy policy is unresolved. That is a reference point analysts and policymakers can apply to any carrier reporting strong individual-market margins in 2026, Oscar included. It is a voluntary commitment for one year, not a regulatory constraint, and it does not change the statutory 80% minimum loss ratio that already applies to the individual market.
Timothy Noel (President, UnitedHealthcare): In the individual ACA market, we re-priced nearly all states in response to higher medical trends and the elevated needs of ACA beneficiaries in 2025. These actions were necessary to ensure a sustainable foundation in these plans and enable us to maintain our participation in all the states we served in 2025. We are working with CMS on solutions to address consumer affordability challenges given the unfolding dynamics in the ACA marketplace. As we announced last week, we have voluntarily pledged to rebate ACA market profits back to our ACA customers this year as policymakers work to determine how to improve affordability in this marketplace. We expect both fully insured group and individual enrollment to contract and be partially offset by continued momentum in our group self-funded offerings.
p. 2 · Read in context →
Answering an analyst who asked how United's 1.3–1.4 million commercial risk-life decline splits between group and exchanges. Two disclosures matter here. United expects to shed more than 500,000 exchange members in 2026 — supply that has to land somewhere, and Oscar grew members 56% year over year in the same open enrollment. And management sets its own 2026 exchange margin expectation at roughly 1%, plus or minus 1%, while describing more than a decade in the market as never a significant earnings contributor. That is United's economics on its own book, not a market-wide margin ceiling; it does establish what the largest national carrier thinks the business is worth after repricing.
Dan Schumacher (Executive): On membership pertaining to the risk-based decline, the largest share of that membership decline is connected to our exchange business for 2026, where we continue to expect meaningful decline between now and the end of the year. […] So to parse that out specifically, 500,000 plus is attributable to the exchange business, and the remainder, to those three factors. Moving to margins, and first addressing the exchange business; over the course of the decade plus in which we have operated in that market, it has never been a significant contributor of earnings for us. Our pricing posture for 2026 coming out of 2025 is going to return that market to a positive margin business for us. However, I would expect those margins in the exchange business for 2026 to be in about the 1% range, plus or minus 1% for that business.
p. 10 · Read in context →
The Cigna Group (Cigna Healthcare individual exchange) (CI)
The peer that ran the margin-over-growth strategy first and then left. Cigna cut its individual exchange book from nearly 1 million customers in 2023 to under 400,000 by mid-2025 while the market grew, and in April 2026 announced it will exit the business entirely at the end of the year. That sequence is the clearest peer articulation of the trade Oscar is on the other side of, and Cigna's own numbers are the most usable market-growth datapoint in this set. Only the Cigna Healthcare individual exchange discussion is used here; Evernorth (PBM, specialty pharmacy, care services), stop-loss and international are outside the comparison.
The most direct market-sizing statement any peer makes in this set: Cigna's management puts industry individual-exchange enrollment up nearly 50% from 2023 to mid-2025, against its own book falling from nearly 1 million to under 400,000, after two consecutive pricing cycles at roughly double the industry average increase. "Some of our competitors showed meaningful growth" is the unnamed reference — Oscar roughly tripled membership over the same window. Read level-headed, this is a competitor explaining why it declined share that Oscar took, and asserting the share was unprofitable; the 2025 industry-wide risk-adjustment shock that followed is the argument for its side of the case.
Brian C. Evanko (President and Chief Operating Officer): I think it's important to step back and rewind the clock a couple of years to 2023. At that point in time, we served nearly 1 million customers in the individual exchanges, albeit with mixed financial performance. Based upon our performance as well as our forward view of the market, we made the strategic choice to prioritize margin over growth, which included adjustments to product and network strategies, refinements to our geographic footprint, and increased prices where necessary. And this decision to prioritize margin over growth in the individual exchanges has helped us to navigate some of the industry-wide pressures that have emerged here in 2025. And we now serve fewer than 400,000 customers in this business, down materially from the nearly 1 million we served in 2023. Additionally, across both the 2024 and 2025 pricing cycles, our nationwide price increases were roughly double the industry average in each of those years. So as a result of those actions, some of our competitors showed meaningful growth in their individual exchange businesses, while we chose to reposition our portfolio, which resulted in fewer individual exchange customers for Cigna Healthcare. […] Meanwhile, across the industry, individual exchange enrollment is up nearly 50% over that same time period.
p. 8 · Read in context →
Cigna's 2026 membership plan as given in February 2026 — flat total medical customers, with individual exchange declining and employer and international growing. Two months later the company announced it would leave the exchange business altogether, so this is the last statement of the shrink-but-stay posture before it became an exit. The 18.1 million figure is total Cigna Healthcare medical customers across all lines, the large majority of it employer-sponsored; the individual exchange book was under 400,000.
Brian Evanko (President and Chief Operating Officer): So as it relates to the Cigna Healthcare membership outlook, as you saw in the press release, we expect flat year over year at about 18.1 million lives. And really, you can think of that big picture as we expect growth in our US Employer and international health businesses offset by a decline in individual exchange customers.
p. 12 · Read in context →
The exit announcement, made on Cigna's Q1 2026 call by the incoming CEO and framed as portfolio discipline rather than a judgment on the market's economics — it is presented alongside a strategic review of eviCore as part of the same tidying. For Oscar the mechanical consequence is on the 2027 open enrollment: under 400,000 Cigna members will need new carriers, in a market where Aetna has already gone and Molina is deliberately shrinking. Cigna gives no state-level breakdown, so how much of that book overlaps Oscar's footprint is not determinable from this document.
Brian Evanko (President and Chief Operating Officer, incoming Chief Executive Officer): On the other end of the spectrum are the businesses we have divested where the assets no longer support our strategic direction or have reduced management focus from our core growth platforms. […] In keeping with this portfolio shaping discipline, today, we are announcing two additional actions. First, we are planning to exit our individual exchange business at the end of this year. We did not make this decision lightly and appreciate the importance of ensuring patients have continuity through the transition. There are no changes to coverage or networks related to this announcement, and we will support members through their open enrollment transitions into 2027.
p. 3 · Read in context →
Molina Healthcare, Inc. (Marketplace segment) (MOH)
The clearest counter-case to Oscar's strategy. Molina is deliberately pricing itself out of the Marketplace — roughly 30% average rate increases for 2026, a book cut to 280,000 members, and a stated plan to shrink again in 2027 — and its management explains, in unusual mechanical detail, the adverse-selection dynamic it believes makes a shrinking individual book dangerous. Only the Marketplace segment is used here; Molina's Medicaid business (the large majority of its $42 billion premium) and its Medicare duals business are outside the comparison.
Molina's Marketplace scale as of Q1 2026, for reference against Oscar's 3.2 million: 305,000 members declining to a planned 250,000 by year end, 70% of it renewals. Molina describes the shrinkage as intended. The comparison is one of strategy rather than of like books — Molina is a Medicaid-first company for which Marketplace is a small adjacency, while it is essentially all of Oscar.
Mark Keim (Chief Financial Officer): Meanwhile, Marketplace sold moderately higher paid renewals, ending the first quarter at 305,000. With normal market attrition, we expect membership in our Marketplace segment to end the year at approximately 250,000. Renewing members now represent 70% of our book.
p. 3 · Read in context →
Molina's July 2026 guidance cut on Marketplace — a $1.50 per share swing from gain to loss, medical cost ratio taken to 90%, and an explicit commitment to shrink the footprint again for 2027. The stated cause is not weak pricing but member acuity mix, which management attributes to the shrinking itself. This is a peer treating the individual market as a business to allocate capital away from in the same quarter Oscar is guiding to $18.7–19.0 billion of revenue in it; the segment is small enough for Molina that exiting is cheap in a way it is not for a pure-play.
Joseph Zubretsky (President and Chief Executive Officer): In Marketplace, our full year MCR guidance is now 90%. We are reducing our marketplace guidance by $1.50 per share from a gain of approximately $0.75 to a loss of $0.75 due to prior year items and current year unfavorable member acuity mix. Looking forward, we plan to again reduce our footprint and volumes in 2027 to minimize our exposure to this segment. […] However, marketplace guidance decreases by $1.50 of earnings per share as our process of deemphasizing and downsizing this business in the portfolio bears the cost of higher member acuity mix.
p. 2 · Read in context →
The mechanics behind Molina's write-down, and the most transferable piece of analysis any peer offers here. Management's account: price to be uncompetitive, the healthy leave first, the chronically ill stay for network and formulary continuity even at $50–100 a month more, and their spending shows up as high-cost drug utilization without matching HCC diagnosis codes — so risk adjustment does not fund it. Note the direction of the argument runs against a carrier that is losing share, not gaining it, and Molina concedes the market-wide acuity shift was milder than it priced for. Whether the same coding-versus-cost gap appears in a growing book is the open question it raises for Oscar.
Joseph Zubretsky (President and Chief Executive Officer): But as you recall, coming into 2026, we put on average 30% rate increases into the market, ranging from around 30% up to higher levels depending on the state, all with the sole purpose of allocating less capital to the business and reducing our footprint. Recall that we positioned the product to be #1 or #2 priced in only a handful of markets. And we were successful in doing that, now at $2.5 billion of premium and 280,000 members. We did include an element in pricing to account for the potential for an acuity shift. Now the Wakely reports are showing that acuity shift is probably less in the entire market, but we're not a microcosm of the entire market. At 280,000 members, we had more adverse selection, if you will, or member acuity mix than the rest of the market. […] It's really a simple case: as the book shrinks in size consciously due to our positioning of the product and the pricing, the old adage in insurance is people that need coverage are going to seek it. So we certainly priced for an acuity shift. Many of these members are on high-cost drug therapies — HIV, oncology and the like. And even with a $50, $75 or even $100 per month price difference, they tend to stay with the health plan that they're comfortable with, that their drug therapies will be prescribed and paid for. So we're seeing a lot of that. We're seeing high-cost drug utilization without corresponding HCCs to drive risk adjustment, which is creating an imbalance.
p. 5 · Read in context →
CVS Health Corporation (Aetna individual exchange) (CVS)
The largest single block of supply removed from the 2026 risk pool. Aetna exited the individual exchange business entirely for 2026 after a $448 million premium deficiency reserve on the 2025 coverage year, and CVS quantifies the resulting membership loss in its own results. That exit is part of the market structure behind Oscar's 56% membership growth in the same open enrollment. Only the Aetna/Health Care Benefits individual exchange discussion is used here; Caremark, retail pharmacy, Oak Street and Signify are outside the comparison.
CVS's CEO characterising the Aetna exchange exit, on the Q3 2025 call. The framing is worth noting for what it is: the exit is listed as a portfolio decision alongside an acquisition, with no market-level judgment attached. Elsewhere on the same call the CFO attributes part of the quarter's 92.8% medical benefit ratio to higher acuity in the individual exchange product line and to worsening exchange risk-adjustment expectations based on the Wakely data — the underlying reason, stated separately from the decision.
David Joyner (President and Chief Executive Officer): In my first year as CEO, I have pushed our team to act with urgency and focus as we execute on opportunities to improve our business. This means making thoughtful and difficult decisions, such as exiting our individual exchange business or taking advantage of market opportunities like our acquisition of the Rite Aid assets.
p. 1 · Read in context →
The exit quantified in CVS's own Q1 2026 results: roughly 600,000 medical members lost sequentially, attributed primarily to leaving the exchange business. Combined with UnitedHealthcare's expected 500,000-plus exchange decline and Centene's move from about 5.0 million to 3.5 million, this is the supply side of the 2026 individual market — members displaced by exits and repricing at the same time the subsidy expiration was shrinking the pool. Oscar added members through that open enrollment; how much of the gain is displaced Aetna membership is not determinable from these documents, since neither company publishes state-level or carrier-to-carrier switching data.
Brian Newman (Chief Financial Officer): In Health Care Benefits, we generated nearly $36 billion of revenue in the quarter, an increase of over 3% from the prior year. This increase was primarily driven by our government business, partially offset by our exit from the Individual Exchange business in 2026. We ended the quarter with approximately 26 million medical members, which declined sequentially by approximately 600,000 members. This decrease was primarily driven by our exit from the Individual Exchange business in 2026, partially offset by growth in our commercial fee-based membership.
p. 3 · Read in context →
More peer documents
Centene — Q2 FY2025 earnings call — Q2 FY2025 · 14 pages · Page 1 is the anatomy of the July 2025 risk-adjustment shock that hit the whole market — a $2.4bn full-year pretax hit, the three causes management assigns (healthy members exiting on program-integrity rules, higher-morbidity new sign-ups, more aggressive provider coding) and the claim that market morbidity moved 16–17% year over year in some states. · Open →
Centene — Q3 FY2025 earnings call — Q3 FY2025 · 13 pages · Page 11 is the CEO answering directly on long-term commitment to the exchange business and on ICHRA — the closest a peer comes to arguing Oscar's own thesis, including the view that growth can come from the uninsured even without enhanced subsidies. · Open →
Centene — FY2025 Form 10-K — FY2025 · 130 pages · Page 28's risk factor is the filed-document version of the competitive threat: competitors introducing pricing or broker incentives Centene cannot match, competitors exiting and stranding risk-adjustment receivables, and the admission that 2026 refiled rates may not restore profitability. · Open →
Molina Healthcare — FY2025 Form 10-K — FY2025 · 102 pages · Page 15 lays out the Marketplace Program Integrity and Affordability Rule mechanics that reshape the risk pool — shortened open enrollment from 2027, the repealed 150%-FPL special enrollment period, tightened verification — plus which provisions sunset at end-2026 and which are stayed in litigation. · Open →
UnitedHealth Group — Q2 FY2026 earnings call — Q2 FY2026 · 16 pages · Page 7 has UnitedHealthcare stating its exchange business is running better than planning expectations but contributing nothing to results because of the profit-rebate pledge — the mid-year update on how that commitment is being applied. · Open →
CVS Health — FY2025 Form 10-K — FY2025 · 185 pages · Page 111 has the accounting behind the Aetna exit: a $448m premium deficiency reserve taken in Q1 2025 on the individual exchange product line for the remainder of the coverage year, following a $270m reserve on the same line in Q3 2024. · Open →
Elevance Health — Q2 FY2026 earnings call — Q2 FY2026 · 13 pages · Pages 7–8 continue into the bidding-posture question for ACA and Medicare Advantage, and give Elevance's framing of Medicaid acuity normalisation — useful for separating individual-market dynamics from the Medicaid trend story that dominates most peer calls. · Open →