Molina Healthcare, Inc. (MOH): Lienzo del Modelo de Negocio [Actualizado en Ene-2025]

En el complejo panorama del seguro de salud, Molina Healthcare se destaca como un jugador fundamental que transforma cómo las poblaciones de bajos ingresos y vulnerables acceden a los servicios médicos asequibles. Al navegar estratégicamente por los programas de salud gubernamentales y aprovechar la tecnología innovadora, Molina Healthcare ha creado un modelo de negocio único que va más allá de los paradigmas de seguros tradicionales. Su enfoque combina cobertura integral, apoyo personalizado del paciente y soluciones rentables, lo que hace que la atención médica sea más accesible y receptiva a las necesidades de los beneficiarios de Medicaid y Medicare en múltiples estados.

Molina Healthcare, Inc. (Moh) - Modelo de negocios: asociaciones clave

Agencias gubernamentales (Medicaid, programas de Medicare)

Molina Healthcare mantiene asociaciones críticas con agencias estatales de Medicaid en 19 estados a partir de 2024. El valor total de los contratos de Medicaid valora aproximadamente $ 22.3 mil millones en ingresos anuales.

Programas estatales de Medicaid	Valor de contrato	Vidas cubiertas
California	$ 5.6 mil millones	1.2 millones
Texas	$ 3.9 mil millones	850,000
Florida	$ 2.7 mil millones	600,000

Proveedores de atención médica y hospitales

Red de aproximadamente 250,000 proveedores de atención médica y 5,800 hospitales en todo el país.

• Red de médico de atención primaria: 85,000 proveedores
• Red especializada: 165,000 proveedores
• Cobertura de asociación hospitalaria: 98% de las áreas de servicio

Compañías farmacéuticas

Asociaciones directas con 12 principales fabricantes farmacéuticos para adquisiciones y manejo de drogas.

Socio farmacéutico	Volumen de prescripción anual	Descuento negociado
Salud CVS	4.2 millones de recetas	23% de descuento
Scripts expresos	3.8 millones de recetas	21% de descuento

Proveedores de tecnología para sistemas de gestión de atención médica

Inversiones de asociación tecnológica por un total de $ 187 millones en 2024 para sistemas avanzados de gestión de salud.

• Sistemas épicos: integración de registros de salud electrónicos
• Cerner Corporation: Gestión de la salud de la población
• IBM Watson Health: plataforma de análisis con IA

Corredores de seguros e intermediarios

Colaboración con 2,300 corredores e intermediarios de seguros, generando $ 1.5 mil millones en canales de ingresos indirectos.

Categoría de corredor	Número de corredores	Comisión anual
Corredores nacionales	350	$ 450 millones
Corredores regionales	1,950	$ 1.05 mil millones

Molina Healthcare, Inc. (Moh) - Modelo de negocio: actividades clave

Administración de servicios de salud administrados

A partir del cuarto trimestre de 2023, Molina Healthcare logró aproximadamente 4,1 millones de miembros en múltiples estados. La compañía opera en 21 estados, proporcionando servicios de seguro de salud de Medicaid, Medicare y Marketplace.

Presencia estatal	Número de estados	Total de miembros administrados
Atención administrada de Medicaid	16	3.2 millones
Planes de Medicare	12	560,000
Planes del mercado	15	350,000

Procesamiento de reclamos y gestión de costos médicos

En 2023, Molina procesó más de 45 millones de reclamos de atención médica con un tiempo de procesamiento promedio de 10-14 días. La relación de pérdida médica se mantuvo en 87.3%.

• Reclamos totales procesados ​​anualmente: 45.2 millones
• Tiempo de procesamiento promedio de reclamos: 12 días
• Eficiencia de gestión de costos médicos: relación de pérdida médica del 87.3%

Desarrollo de redes y gestión de proveedores

Molina Healthcare mantiene una red integral de proveedores de 95,000 profesionales de la salud en sus estados operativos.

Tipo de proveedor	Número de proveedores
Médicos de atención primaria	38,500
Especialistas	42,000
Hospitales y clínicas	14,500

Diseño de productos de seguro de salud

En 2023, Molina ofreció 127 productos de seguro de salud distintos en varios segmentos de mercado con ingresos de primas totales de $ 24.1 mil millones.

• Productos totales de seguro de salud: 127
• Ingresos premium: $ 24.1 mil millones
• Segmentos de productos: Medicaid, Medicare, mercado

Programas de coordinación y bienestar de la atención al paciente

Molina invirtió $ 340 millones en iniciativas de coordinación y bienestar de la atención en 2023, atendiendo a aproximadamente 1,5 millones de pacientes a través de programas especializados.

Categoría del programa de bienestar	Pacientes atendidos	Inversión
Manejo de enfermedades crónicas	750,000	$ 180 millones
Cuidados preventivos	450,000	$ 95 millones
Apoyo de salud mental	300,000	$ 65 millones

Molina Healthcare, Inc. (Moh) - Modelo de negocio: recursos clave

Profesionales de seguros de salud con licencia

A partir del cuarto trimestre de 2023, Molina Healthcare empleó a 4.700 empleados en total. Desglose profesional de la salud:

Categoría profesional	Número de profesionales
Especialistas de seguros de credenciales	1,235
Gerentes de atención clínica	892
Expertos de cumplimiento y regulación	413

Infraestructura avanzada de tecnología de salud

Inversión tecnológica para 2023: $ 127.3 millones

• Sistemas de gestión de salud basados ​​en la nube
• Plataformas digitales que cumplen con HIPAA
• Infraestructura de telesalud

Redes integrales de proveedores médicos

Estadísticas de cobertura de red:

Métrico de red	2023 datos
Proveedores de atención médica totales	86,500
Estados con presencia de red	19
Hospitales en la red	3,742

Capital financiero para la gestión de riesgos

Recursos financieros al 31 de diciembre de 2023:

• Activos totales: $ 8.9 mil millones
• Efectivo e inversiones totales: $ 3.2 mil millones
• Relación de capital basada en el riesgo: 435%

Análisis de datos y capacidades de gestión de la salud de la población

Inversión de infraestructura de análisis: $ 42.6 millones en 2023

Capacidad analítica	Métrico
Modelos de salud predictivos	127 modelos activos
Capacidad de procesamiento de datos	4.2 petabytes por mes
Algoritmos de aprendizaje automático	93 algoritmos implementados

Molina Healthcare, Inc. (Moh) - Modelo de negocio: propuestas de valor

Cobertura de atención médica asequible para poblaciones de bajos ingresos

A partir del cuarto trimestre de 2023, Molina Healthcare sirvió aproximadamente 4,4 millones de miembros en 21 estados. La prima promedio de la compañía por miembro por mes (PMPM) fue de $ 267.53 para los planes de atención administrada de Medicaid y Medicare.

Segmento de miembros	Totales miembros	Prima mensual promedio
Seguro de enfermedad	3.2 millones	$245.67
Seguro médico del estado	1.2 millones	$312.40

Servicios especializados de atención administrada de Medicaid y Medicare

Los ingresos de 2023 de Molina Healthcare de los programas de salud patrocinados por el gobierno totalizaron $ 8.2 mil millones, con un enfoque en servicios especializados de atención administrada.

• Servicios de atención administrada de Medicaid en 16 estados
• Planes de ventaja de Medicare en 14 estados
• Planes de necesidades especiales de doble elegible (D-SNP) en 12 estados

Planes integrales de seguro de salud con enfoque de atención preventiva

La compañía invirtió $ 127 millones en programas de atención preventiva y bienestar en 2023, lo que representa el 1.55% de los ingresos totales de los servicios de salud.

Servicios de atención preventiva	Inversión anual	Porcentaje de ingresos
Programas de bienestar	$ 67 millones	0.82%
Exámenes preventivos	$ 60 millones	0.73%

Apoyo personalizado para el paciente y gestión de la atención

Molina Healthcare empleó a 2,643 profesionales de gestión de atención en 2023, con una carga de casos promedio de 375 pacientes por gerente de atención.

• Línea directa de soporte de enfermería 24/7
• Programas de manejo de enfermedades crónicas
• Servicios de consulta de telesalud

Soluciones de salud rentables para poblaciones vulnerables

En 2023, el índice de costos administrativos de la compañía fue de 8.2%, con una relación de pérdida médica del 88.3%, lo que demuestra una gestión eficiente de costos para poblaciones vulnerables.

Métrico de costo	Porcentaje	Monto del dólar
Costos administrativos	8.2%	$ 672 millones
Relación de pérdida médica	88.3%	$ 7.24 mil millones

Molina Healthcare, Inc. (Moh) - Modelo de negocios: relaciones con los clientes

Plataformas de servicio al cliente digital

Molina Healthcare opera una plataforma integral de servicio al cliente digital con las siguientes métricas clave:

Característica de la plataforma	Datos cuantitativos
Usuarios de aplicaciones móviles	1.2 millones de usuarios activos a partir del cuarto trimestre 2023
Accesibilidad al portal en línea	Disponible en 12 estados con acceso 24/7
Procesamiento de reclamos digitales	92% de las reclamaciones procesadas electrónicamente

Apoyo de gestión de cuidado personal

Molina Healthcare proporciona una gestión de atención personalizada con métricas de apoyo específicas:

• Tamaño del equipo de gestión de atención: 1.500 profesionales dedicados
• Tiempo promedio de interacción del paciente: 45 minutos por caso
• Cobertura de manejo de enfermedades crónicas: 86% de los pacientes inscritos

Programas de educación sobre salud comunitaria

Las iniciativas de salud comunitaria incluyen:

Tipo de programa	Alcanzar	Participantes anuales
Prevención de la diabetes	15 estados	78,500 participantes
Talleres de salud mental	10 estados	45,300 participantes

Canales de atención al cliente dedicados

Detalles de la infraestructura de atención al cliente:

• Personal del centro de llamadas: 850 representantes a tiempo completo
• Tiempo de respuesta promedio: 3.2 minutos
• Calificación de satisfacción del cliente: 4.3/5

Comunicación regular de salud y bienestar

Métricas de estrategia de comunicación:

Canal de comunicación	Puntos de contacto anuales
Boletines por correo electrónico	6 por año por miembro
Recordatorios de salud de SMS	12 por año por miembro
Informes de salud personalizados	2 informes completos anualmente

Molina Healthcare, Inc. (Moh) - Modelo de negocios: canales

Portales de seguros en línea

Molina Healthcare opera múltiples portales de seguros en línea con las siguientes características:

Característica de portal	Datos estadísticos
Usuarios activos mensuales	327,456 usuarios
Tasa de envío de reclamos en línea	68.3%
Compromiso del portal de miembros digitales	42.7% de la membresía total

Aplicaciones móviles

Los canales de aplicación móvil de Molina Healthcare incluyen:

• Disponibilidad de la plataforma iOS y Android
• Conteo de descarga de la aplicación: 214,000
• Usuarios mensuales de aplicaciones móviles activas: 89,750

Representantes de ventas directas

Métrico de canal de ventas	Datos cuantitativos
Representantes de ventas directas totales	1.237 representantes
Ventas anuales promedio por representante	$742,000
Cobertura geográfica	15 estados

Corredores de seguro

Estadísticas de la red de corredores de Molina Healthcare:

• Total de corredores contratados: 2,456
• Tasa de la comisión de corredores: 3-5% por inscripción
• Membresía generada por los corredores: 22.6% de la membresía total

Servicios de consulta de telesalud

Métrica de telesalud	Datos actuales
Consultas de telesalud mensuales	87,300 consultas
Duración de consulta promedio	23 minutos
Tasa de satisfacción del paciente	94.2%

Molina Healthcare, Inc. (Moh) - Modelo de negocio: segmentos de clientes

Individuos y familias de bajos ingresos

A partir del cuarto trimestre de 2023, Molina Healthcare atiende a aproximadamente 4,1 millones de miembros de Medicaid en 19 estados. El gasto de salud anual promedio para este segmento es de $ 6,700 por miembro.

Cobertura estatal de Medicaid	Número de miembros
California	1,250,000
Texas	650,000
Florida	425,000

Poblaciones elegibles para Medicaid

En 2023, el segmento de clientes elegible para Medicaid Medicaid de Molina Healthcare representaba el 76% de su base de membresía total, totalizando aproximadamente 3.1 millones de personas.

• Umbral de ingresos de elegibilidad: 138% del nivel federal de pobreza
• Premio mensual promedio por miembro de Medicaid: $ 312
• Cobertura geográfica: 19 estados

Beneficiarios de Medicare

A partir de 2023, Molina Healthcare cubre 352,000 miembros de Medicare Advantage, con un rango de edad promedio de 65-75 años.

Segmento de Medicare	Número de miembros
Ventaja de Medicare	352,000
Medicare/Medicaid de doble elegible	186,000

Individuos con condiciones de salud crónicas

En 2023, el 42% de la membresía total de Molina Healthcare (aproximadamente 1,7 millones de miembros) tienen una o más condiciones de salud crónicas.

• Miembros del programa de gestión de la diabetes: 580,000
• Manejo de enfermedades cardiovasculares: 420,000
• Gestión de la salud del comportamiento: 350,000

Programas de salud del gobierno estatal y federal

Los ingresos totales del programa gubernamental de Molina Healthcare en 2023 fueron de $ 22.4 mil millones, con un 92% derivado de los contratos de Medicaid y Medicare.

Programa gubernamental	Contribución de ingresos
Seguro de enfermedad	$ 16.5 mil millones
Seguro médico del estado	$ 5.9 mil millones

Molina Healthcare, Inc. (Moh) - Modelo de negocio: Estructura de costos

Reclamos médicos y gastos de reembolso

Para el año fiscal 2023, Molina Healthcare informó gastos de reclamos médicos de $ 22.3 mil millones. La relación de pérdida médica (MLR) fue de aproximadamente el 87.4%, lo que indica el porcentaje de ingresos premium gastados en reclamos médicos y servicios de atención médica.

Categoría de gastos	Monto ($ mil millones)	Porcentaje de costos totales
Gastos de reclamos médicos	22.3	75.2%
Reembolsos de proveedores	18.7	63.1%

Mantenimiento de la infraestructura tecnológica

Molina Healthcare invirtió $ 347 millones en tecnología e infraestructura digital en 2023, lo que representa el 1.2% de los gastos operativos totales.

• Infraestructura de computación en la nube: $ 124 millones
• Sistemas de ciberseguridad: $ 89 millones
• Software de gestión de atención médica: $ 134 millones

Salarios y beneficios de los empleados

La compensación total de los empleados para 2023 fue de $ 1.8 mil millones, que cubrió aproximadamente 22,000 empleados.

Tipo de compensación	Cantidad ($ millones)
Salarios base	1,320
Beneficios de atención médica	270
Bonos de rendimiento	210

Costos de cumplimiento regulatorio

Molina Healthcare gastó $ 215 millones en cumplimiento regulatorio y requisitos legales en 2023.

• Licencias y tarifas de acreditación: $ 62 millones
• Sistemas de monitoreo de cumplimiento: $ 83 millones
• Servicios legales y de consultoría: $ 70 millones

Gastos de marketing y adquisición de clientes

Los gastos de marketing totalizaron $ 276 millones en 2023, lo que representa el 0.9% de los ingresos totales.

Canal de marketing	Gasto ($ millones)	Porcentaje
Marketing digital	124	45%
Publicidad tradicional	92	33%
Ventas directas	60	22%

Molina Healthcare, Inc. (Moh) - Modelo de negocios: flujos de ingresos

Reembolsos del programa de salud gubernamental

Para el año fiscal 2023, informó Molina Healthcare $ 24.6 mil millones En ingresos totales de los reembolsos del programa de salud gubernamental.

Programa	Ingresos (2023)
Atención administrada de Medicaid	$ 18.3 mil millones
Atención administrada de Medicare	$ 4.7 mil millones
Medicare Parte D	$ 1.6 mil millones

Pagos de primas de personas aseguradas

Los pagos de primas individuales para 2023 totalizaron $ 3.2 mil millones.

Tarifas de servicio de salud por miembro por mes (PMPM)

Las tarifas de servicio de atención médica de PMPM para 2023 se calcularon de la siguiente manera:

• Medicaid PMPM: $ 246.50
• Medicare PMPM: $ 712.30
• Mercado PMPM: $ 398.75

Ingresos del contrato de Medicare y Medicaid

Ingresos por contrato de Medicare y Medicaid para 2023:

Tipo de contrato	Ingresos totales
Contratos de Medicare	$ 6.3 mil millones
Contratos de Medicaid	$ 19.8 mil millones

Ventas de productos de seguro de salud suplementario

Las ventas de productos de seguro de salud suplementario para 2023 ascendieron a $ 1.1 mil millones.

Tipo de producto	Ingresos por ventas
Cobertura dental	$ 312 millones
Cobertura de visión	$ 248 millones
Suplementos de medicamentos recetados	$ 540 millones

Molina Healthcare, Inc. (MOH) - Canvas Business Model: Value Propositions

Molina Healthcare, Inc. focuses its value proposition on delivering accessible, comprehensive, and integrated care to government-sponsored populations, which translates into concrete financial and service metrics for members.

Low or no-cost comprehensive health coverage for low-income populations

Molina Healthcare, Inc. provides managed health care services under the Medicaid and Medicare programs and state insurance marketplaces, aiming to erase inequities in care delivery. As of July 25, 2024, Molina served approximately 5.6 million members across 21 states. The company reaffirmed its full-year 2025 guidance of roughly $42 billion in premium revenue. For specific Marketplace plans, like the Silver 12 150 HMO in Michigan for 2025, the first 4 Primary Care Visits are offered at No Charge. Furthermore, for Molina Medicaid members, virtual care visits are provided at NO COST.

Supplemental benefits (e.g., dental, vision, behavioral health) beyond Original Medicare

Molina Medicare Advantage plans often include extra benefits that Original Medicare does not cover, offering a clear financial advantage over the federal program, which has unpredictable out-of-pocket expenses. For members on specific plans who meet criteria and complete a Health Risk Assessment, Molina Medicare Complete Care plans provide a $150 every month for food and produce allowance. Unused allowance does not carry over to the next month. For behavioral health, one plan offers $0 copay for days 1 - 90 of an inpatient hospital stay, subject to a 190 day lifetime limit for inpatient psychiatric hospital care.

Benefit Category	Molina Medicare 2025 Offering Example	Original Medicare Comparison Point
Food/Produce Allowance	$150 every month (SSBCI)	Not covered
Routine Vision Exam	$0 copay for up to one per calendar year	Not covered
Inpatient Mental Health Days	$0 copay for days 1 - 90 per benefit period	60 lifetime reserve days available after 90 days

Integrated care models for complex and chronic conditions (e.g., D-SNP, MMP)

Molina Healthcare is heavily invested in the Dual Eligible Special Needs Plan (D-SNP) market, which integrates Medicare and Medicaid benefits for complex populations. Overall SNP enrollment grew +21.5% from the prior year, with an average annual growth of +18% over the last five years. As of early 2025, Molina Healthcare served 113,921 members in Special Needs Plans. The company is preparing for future growth, evidenced by the Illinois D-SNP contract win expected to add approximately 73,000 beneficiaries starting in 2026, for which Molina's 2025 guidance includes about $1.00 per diluted share in implementation costs. The consolidated Medical Care Ratio (MCR) for Molina was 89.1% in 2024, with the Medicaid MCR at 90.3%.

Access to virtual care (Teladoc) and 24/7 health support

Molina Healthcare offers access to virtual care through partnerships with providers like Teladoc for adult care and Nemours Children's Health System for pediatric care, enabling 24/7 medical care by phone or video. The company's subsidiary, Care Connections, completed over 250,000 visits across 22 states in 2025, utilizing in-home and telehealth visits from nurse practitioners and social workers to support preventive screenings and chronic disease management. For Marketplace plans, telehealth services are covered at the same cost share as in-person services, and for Medicaid members, these telehealth visits are free.

• Telehealth partners include Teladoc and Nemours Children's Health System.
• Care Connections completed over 250,000 visits in 22 states in 2025.
• Molina Medicaid members receive telehealth services at no cost.
• Telehealth services are covered on the same basis as in-person services.

Community-focused programs addressing social determinants of health

The value proposition includes strategic investment in community health via the MolinaCares Accord to address the root causes of health disparities. Molina supports initiatives targeting essential needs like housing, nutrition, and transportation. For example, the company invested in a doula program, reflecting its commitment to health equity. Molina encourages the use of SDOH screening tools that must, at a minimum, screen for:

• Homelessness/Housing instability
• Transportation Assistance
• Employment Instability
• Justice/Legal Involvement
• Social Isolation/Social Support

Finance: draft 13-week cash view by Friday.

Molina Healthcare, Inc. (MOH) - Canvas Business Model: Customer Relationships

You're looking at how Molina Healthcare, Inc. connects with its members in late 2025, a time defined by significant Medicaid redetermination activity and a push toward digital efficiency. The relationship strategy centers on high-touch support for a complex member base, which, as of September 30, 2025, stood at approximately 5.6 million members across its government-sponsored plans.

High-touch, multi-language Member Services support via phone and TTY

Molina Healthcare maintains a commitment to accessible, direct support channels for its members. This includes dedicated phone and TTY services, which are crucial given the diverse linguistic needs of the Medicaid and Marketplace populations it serves. While specific call center metrics for late 2025 aren't public, the scale of the operation supports millions of members who rely on these immediate touchpoints.

• Member base as of September 30, 2025: approximately 5.6 million.
• Member base as of June 30, 2025: approximately 5.7 million.
• The overall business is heavily reliant on government programs, where personalized service is a key differentiator.

Case managers and care coordinators for complex and high-risk members

For members with higher acuity needs, Molina Healthcare deploys specialized clinical teams. This high-touch approach is necessary because utilization remains a concern, with the consolidated Medical Care Ratio (MCR) hitting 92.6% in the third quarter of 2025. This indicates a significant portion of premium revenue is going toward claims, underscoring the need for proactive management of high-cost utilization areas like behavioral health and pharmacy.

Digital self-service tools through member portals and website

Molina Healthcare is actively shifting administrative processes to digital platforms to streamline interactions for both members and providers. A major step in this direction is the transition to a Digital-Only Prior Authorization (PA) Model, meaning faxes will no longer be accepted after December 31, 2025, requiring all PA requests through the Availity Essentials portal. This move aims for faster turnaround times and greater transparency in authorization tracking for members.

Community engagement and outreach programs (MolinaCares)

The MolinaCares Accord represents tangible, localized investment aimed at addressing Health Related Social Needs (HRSN) and improving community health infrastructure. These are concrete financial commitments designed to build trust and address non-clinical barriers to care.

Initiative/Grant Focus	Amount/Detail	Date/Context
Workforce Development (Nevada AHEC)	$150,000 grant	Announced April 2025
Career/College Readiness (Springfield Project)	$45,000 grant for transportation	Presented March 2025
California Community Reinvestment	Planning started in CY 2025	Activities begin in CY 2026

These community reinvestment activities are designed to align with state goals to improve member health and well-being through locally-driven innovations.

Proactive communication for Medicaid redeterminations and renewals

Managing the Medicaid eligibility redetermination process is a critical, ongoing customer relationship challenge. While the bulk of the disenrollments due to the unwinding occurred earlier, the impact continues to be felt, with Medicaid membership declining 5.2% in the first nine months of 2025. Molina Healthcare previously expected to retain 40% of the membership gained during the pandemic pause. Proactive communication is essential as states continue eligibility checks, directly impacting the ~4.5 million Medicaid members Molina served as of Q3 2025 (estimated from total membership of 5.6 million and other segments).

• Medicaid MCR for Q3 2025 was 92.0%.
• The company is focused on rate adjustments to offset the trend, with 55% of premium re-contracting expected on January 1, 2026.

Finance: draft 13-week cash view by Friday.

Molina Healthcare, Inc. (MOH) - Canvas Business Model: Channels

You're looking at how Molina Healthcare, Inc. (MOH) gets its plans in front of people, which is key since they serve a massive government-sponsored population. It's a multi-pronged approach, but some channels are getting a strategic shake-up as of late 2025.

Direct enrollment through state and federal Health Insurance Marketplaces

Molina Healthcare accepts business directly from consumers for its Marketplace plans. However, the company made a significant channel adjustment by announcing it will not pay agent commissions on new Affordable Care Act (ACA) business in ten states: Florida, New Mexico, Texas, South Carolina, Illinois, Michigan, Wisconsin, Connecticut, Washington, and Ohio. The Marketplace segment has been a tough spot; for Q3 2025, it reported a Medical Care Ratio (MCR) of 95.6%. Looking ahead, the fourth quarter guidance projects Medicare and Marketplace segments will combine for an estimated loss of $2.65 per share against Medicaid's projected earnings.

State-run Medicaid and Medicare enrollment systems

The core of Molina Healthcare's distribution relies on state-run systems for Medicaid and Medicare Advantage enrollment. As of the Q3 2025 report, the Medicaid segment was the powerhouse, accounting for 75% of total premium revenue. The company projects its full-year 2025 premium revenue to hit approximately $42.5 billion. This reliance on government programs means enrollment flows heavily through state eligibility determinations and federal Medicare Advantage plan selection processes. The company served approximately 5.6 million+ members across 21 states as of mid-2024, a base they are actively growing through contract wins.

Independent brokers and agents for Medicare Advantage and Marketplace plans

Brokers and agents remain a vital channel, particularly for Medicare Advantage and Marketplace plans, though Molina Healthcare is adjusting incentives. For new 2025 enrollments effective January 1 or February 1, 2025, Molina offered one-time bonuses to agents based on volume and plan type. Renewal business also saw bonus payouts in July 2025. Here's a look at the one-time bonus structure for new 2025 members:

Total # of New Members	Plan Type	One-Time Bonus Amount per Member (Lower Tier)	One-Time Bonus Amount per Member (Higher Tier)
50 +	Silver Plans	$50	$75
50 +	Bronze Plans	$25	$50
100 +	Silver Plans	$50	$75
100 +	Bronze Plans	$25	$50

To be fair, this structure had specific terms, like requiring members to remain enrolled for 120 days. Also, beginning with 1/01/26 enrollments, new sales commissions will be paused for Molina's CHP MAPD and CHP C-SNP products in California, though renewal commissions will continue.

Direct-to-member communication via mail, email, and digital platforms

Molina Healthcare supports direct enrollment and member engagement through digital and physical outreach. Members can access their Member Portal at MyMolina.com to view benefits, print ID cards, and track claims. The company also offers the Molina Mobile App for on-the-go access. For payments, members can use Molinapayment.com for one-time transactions or sign up for Autopay. Interpreter services are provided at no cost to assist any Member needing language support.

Local community offices and health centers for in-person support

While the primary focus is government-sponsored care delivered through established state systems, Molina Healthcare maintains a physical presence. The company is headquartered in Long Beach, California. In-person support channels are crucial for members navigating complex eligibility or benefit questions, especially within the Medicaid and Medicare populations. For example, in Texas, Molina Healthcare of Florida, Inc. serves specific counties like Broward, Miami-Dade, and Orange.

Finance: draft 13-week cash view by Friday.

Molina Healthcare, Inc. (MOH) - Canvas Business Model: Customer Segments

Molina Healthcare, Inc. focuses its business model on serving government-sponsored healthcare programs. You are looking at a customer base heavily concentrated in public health insurance markets.

As of September 30, 2025, Molina Healthcare, Inc. served approximately 5.6 million total members.

The primary customer groups are segmented by the source of their coverage, which dictates the regulatory and payment structure Molina operates under for each group.

• Medicaid beneficiaries: low-income families, children, pregnant women, and individuals with disabilities
• Medicare beneficiaries: primarily dual-eligible (Medicare-Medicaid Plans - MMPs) and Medicare Advantage members
• Health Insurance Marketplace (ACA) enrollees: individuals and families seeking subsidized coverage

Here's a look at the membership distribution across these core segments based on the latest figures available for the third quarter of 2025.

Customer Segment	Approximate Member Count (as of 9/30/2025)	Segment Premium Revenue (Q3 2025)
Medicaid	More than 4.6 million	$8.02 billion
Health Insurance Marketplace (ACA)	713,000	Not explicitly stated for Q3 2025
Medicare Advantage	266,000	Not explicitly stated for Q3 2025
Total Reported Members	Approximately 5.6 million	$10.8 billion (Consolidated Premium Revenue for Q3 2025)

The Medicaid segment remains the cornerstone of Molina Healthcare, Inc. operations, representing the largest portion of the total membership base. In the third quarter of 2025, this flagship business accounted for approximately 75% of total premium revenue. You can see the financial performance pressures, with the Medicaid Medical Care Ratio (MCR) reported at 92.0% for that quarter.

The Health Insurance Marketplace (ACA) segment experienced significant growth in membership leading up to this period, though it also faced notable utilization challenges. For the third quarter of 2025, the Marketplace MCR was reported at 95.6%. The Medicare segment, which includes dual-eligible plans, also saw higher utilization, posting a third quarter MCR of 93.6%.

Molina Healthcare, Inc. (MOH) - Canvas Business Model: Cost Structure

You're looking at the cost side of Molina Healthcare, Inc.'s (MOH) operations as of late 2025, and frankly, the story is dominated by medical claims. It's where the vast majority of premium revenue goes. For the third quarter of 2025, the consolidated Medical Care Ratio (MCR), which is the percentage of premiums spent on member care, hit 92.6%. That's a significant cost base right there.

The pressure on that MCR is coming from utilization across the board, but it's not evenly distributed. The Marketplace segment, which is a smaller piece of the overall business, is seeing the most acute pressure. The Q3 2025 MCR for Marketplace was 95.6%, driven by much higher utilization than their risk adjustment revenue could cover.

Here's a quick breakdown of the key cost ratios from the third quarter of 2025:

Cost Component	Q3 2025 Ratio	Context/Guidance
Consolidated Medical Care Ratio (MCR)	92.6%	Reported for Q3 2025
Adjusted General and Administrative (G&A) Ratio	6.3%	Reported for Q3 2025
GAAP General and Administrative (G&A) Ratio	6.4%	Reported for Q3 2025
Full Year 2025 Adjusted G&A Guidance	~6.5%	Updated guidance
Depreciation and Amortization Expense Ratio	1.0%	Reported ratio from a financial table

The company is managing its overhead costs well, which is important when medical costs are running so high. The adjusted G&A ratio for Q3 2025 was held to 6.3%, showing continued operating discipline even as premium revenue for the quarter was approximately $10.8 billion.

When you look deeper into the utilization trends that are inflating the MCR, you see specific areas of concern that drive these medical costs:

• Marketplace MCR at 95.6% due to elevated utilization.
• Medicare MCR at 93.6%, reflecting higher utilization in high-acuity members.
• Higher utilization in Medicare is specifically tied to long-term services and supports (LTSS) and pharmacy costs.
• Medicaid MCR was 92.0% for the quarter, which management still characterized as producing strong margins relative to the other segments.

Beyond the direct claims, there are the structural costs. The amortization of intangible assets from strategic acquisitions is a component of the overall cost base, and the closest available figure for a related expense category, the Depreciation and amortization expense ratio, was 1.0% in one reported period. Then you have the ongoing spend for state and federal regulatory compliance and quality improvement costs, which are baked into the G&A structure or other operating expenses, but a specific standalone dollar amount for this category in 2025 isn't explicitly broken out in the primary cost disclosures.

Molina Healthcare, Inc. (MOH) - Canvas Business Model: Revenue Streams

Premium Revenue from government capitation payments (Medicaid, Medicare, Marketplace)

• Medicaid segment produced a Q3 2025 Medical Care Ratio (MCR) of 92.0%.
• Medicare segment produced a Q3 2025 MCR of 93.6%.
• Marketplace segment produced a Q3 2025 MCR of 95.6%.
• Q3 2025 Premium revenue was approximately $10.8 billion.

Full-year 2025 Premium Revenue guidance is approximately $42.5 billion.

Risk adjustment and reinsurance payments from government programs

• Marketplace MCR for Q3 2025 was impacted by higher utilization relative to risk adjustment revenue.
• Marketplace MCR guidance for full year 2025 was raised to 85% in one report, while another noted a Q2 2025 MCR of 85.4% including prior-year true-ups.

Investment income on cash reserves and float (less significant)

• Investment income for the nine months ended September 30, 2025, was $322 million.
• Investment income for the third quarter of 2025 was $108 million.

Here's the quick math on the reported revenue components through Q3 2025:

Revenue Component	Amount (Nine Months Ended Sept 30, 2025, in millions)	Amount (Q3 2025, in millions)
Premium revenue	$32,337	$10,841
Premium tax revenue	$1,325	$506
Investment income	$322	$108

Cash and investments at the parent company were approximately $108 million as of September 30, 2025.