Clover Health Investments Q4 Earnings Call Highlights

• Clover achieved full-year Adjusted EBITDA profitability in 2025 and guided to its first full year of GAAP net income profitability in 2026 (net income breakeven to $20M), with Adjusted EBITDA guidance of $50–70M and revenue guidance of $2.81–2.92 billion.

• Medicare Advantage membership grew 38% year‑over‑year to about 114,000 at year‑end (and 53% AEP growth), driven by Clover’s risk‑bearing model, strong retention, and expanded use of the Clover Assistant platform.

• Management said underlying medical cost trends (ex‑pharmacy) were well controlled at ~5% Y/Y, introduced Consolidated Gross Profit as the primary operating metric ($356M in 2025; guidance $470–510M for 2026), and ended the quarter with $320M in cash while using $67M of operating cash mainly from working‑capital timing.

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Clover Health Investments (NASDAQ:CLOV) executives used the company’s fourth-quarter 2025 earnings call to emphasize a combination of profitability and rapid Medicare Advantage membership growth during what they described as a period of elevated utilization across the industry.

Chief Executive Officer Andrew Toy said the “headline takeaway” from 2025 was that Clover achieved full-year Adjusted EBITDA profitability, maintained a well-controlled medical cost trend, and “reestablished market-leading membership growth” despite industrywide utilization pressure and the financial dilution that typically comes with onboarding new Medicare Advantage members. Chief Financial Officer Peter Kuipers added that the company believes it enters 2026 with improving earnings power and a stable benefit design supported by strong retention and deeper use of Clover Assistant.

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Toy said Clover sustained profitability while growing membership by 38% year over year within a model where the company retains full underwriting risk rather than delegating it to providers. He argued that while new members can be dilutive in the first year, profitability improves with tenure as cohorts mature, allowing Clover to capture “the full economic upside.”

Management repeatedly contrasted Clover’s approach with broader Medicare Advantage dynamics. Toy said Clover has long advocated that Medicare Advantage should reward “real clinical value and disciplined cost management,” rather than coding intensity or favorable rate assumptions. He also characterized regulatory and reimbursement pressure on incumbents—such as reduced benefits and market exits—as competitively beneficial for Clover.

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In discussing growth, Toy said Clover delivered 53% year-over-year membership growth during the 2026 annual enrollment period, attributing the results to a stable benefit offering, strong retention, focus on core markets where Clover Assistant coverage is strong, and minimal reliance on e-brokers.

Kuipers reported that Medicare Advantage membership rose 38% year over year to approximately 114,000 members at year-end. Insurance revenue in the fourth quarter was $486 million, up 47% year over year, while full-year 2025 insurance revenue was $1.9 billion, up 41%. Total revenue increased 40% year over year for 2025.

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On cost trends, Kuipers said the company’s underlying medical cost trends excluding pharmacy were “well controlled at 5% year-over-year.” He noted continued cost pressure in outpatient settings during the fourth quarter, consistent with broader industry trends, and described seasonal Part D pressure tied to Inflation Reduction Act (IRA) changes. Despite that, he said Clover improved Part D margin year over year and delivered higher consolidated gross profit in 2025, with performance in line with guidance.

Starting with the quarter, Clover introduced Consolidated Gross Profit as a primary operating metric, defining it as total revenue minus medical claims. Kuipers said the company believes it provides the “clearest view” of consolidated business performance and underlying earnings power and will replace insurance segment BER as the primary operating guidance metric. Consolidated Gross Profit for full-year 2025 was $356 million.

For 2025, insurance segment BER was 90.9%, up 970 basis points year over year. Kuipers said that after normalizing for prior period developments, BER increased by approximately 700 basis points year over year, primarily due to new member dilution and incremental quality investments.

Adjusted SG&A in the fourth quarter was $98 million, which Kuipers said was slightly above expectations due mainly to higher commissions from stronger-than-expected new sales and continued quality-focused investments aimed at improving cohort performance and margins in 2026. Adjusted SG&A as a percentage of total revenue was 20% in the fourth quarter, improving 560 basis points year over year, and 17% for the full year, improving 410 basis points year over year.

For 2025, the company reported $22 million of Adjusted EBITDA and $20 million of adjusted net income. Kuipers said the fourth quarter reflected normal seasonal patterns and argued the full-year results showed Clover could “grow and stay profitable at the same time,” even with higher utilization across the industry.

Clover ended the fourth quarter with $320 million in cash and investments on a consolidated basis, including $122 million at the unregulated subsidiary level. Cash flow used in operating activities was $67 million for the year, which Kuipers attributed primarily to working capital timing related to membership growth.

Kuipers said the company’s capital allocation framework prioritizes balance sheet strength and liquidity, followed by selective reinvestment in initiatives intended to improve long-term economics and deepen clinical integration with Clover Assistant. He added that the company is “not pursuing growth for growth’s sake” and expects to generate meaningful operating cash flow while achieving GAAP net income profitability.

Management said it expects 2026 to be Clover’s first full year of GAAP net income profitability. Kuipers provided guidance ranges that include:

• Average Medicare Advantage membership: 154,000 to 158,000 (46% growth year over year at the midpoint)

• Total revenue: $2.81 billion to $2.92 billion (49% year-over-year growth at the midpoint)

• Consolidated Gross Profit: $470 million to $510 million

• Adjusted EBITDA: $50 million to $70 million

• Net income: breakeven to $20 million (expected first full year of GAAP net income profitability)

Kuipers said Clover targets reducing Adjusted SG&A as a percentage of total revenue by approximately 100 to 150 basis points year over year, while keeping flexibility to reinvest in quality improvement, care management, and research and development.

He outlined several drivers behind the company’s confidence, including strong 2025 execution and underwriting discipline, AEP retention above 95% resulting in a larger returning member base, a “four-star payment year” for PPO plans with about 97% of members enrolled in the wide network PPO, expected benefit from the 2026 Part C final rate notice, expanding Clover Assistant coverage and primary care adoption, directing intra-year growth to more cost-efficient acquisition channels, Part D optimization initiatives for a second year of IRA changes, targeted remediation and recovery actions to address abnormal dental and DME activity experienced in 2025, and continued SG&A leverage with scale.

During Q&A, Kuipers and Toy addressed a question about why gross profit margin appears to step down year over year despite the four-star payment year, pointing to the dilutive effect of bringing in a large new cohort following 53% AEP growth. Toy said management was “pretty pleased” that the step-down was limited given the scale of growth. Management also said early-year profitability for new members was in line with expectations based on MMR files and noted utilization was down in January and February year-to-date for the total population.

On policy, Toy reiterated support for CMS efforts to strengthen linkages between claims and clinical documentation, while flagging what he described as an oversight involving “switchers,” where a new plan may lack data needed for linking. He said CMS could address that gap by sharing the relevant data.

Finally, Toy said Counterpart Health remains a strategic priority, with a near-term goal of managing as many members under Counterpart Assistant as under Clover Assistant, though management said it had nothing to add yet on economic contribution within 2026 guidance.

Clover Health Investments is a technology-driven healthcare company specializing in Medicare Advantage plans for senior populations. The company combines insurance coverage with a proprietary software platform to improve care coordination, outcomes tracking and cost management. By leveraging data analytics, Clover Health aims to deliver personalized care pathways and preventive interventions for its members.

At the core of Clover’s offering is its Clover Assistant platform, which aggregates clinical and claims data from multiple sources to create real-time insights for physicians and care teams.

The article “Clover Health Investments Q4 Earnings Call Highlights” was originally published by MarketBeat.