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Cigna (NYSE:CI)

Q1 2014 Earnings Call

May 01, 2014 8:30 am ET

Executives

Edwin J. Detrick - Vice President of Investor Relations

David M. Cordani - Chief Executive Officer, President, Director and Member of Executive Committee

Thomas A. McCarthy - Chief Financial Officer and Executive Vice President

Analysts

Scott J. Fidel - Deutsche Bank AG, Research Division

Joshua R. Raskin - Barclays Capital, Research Division

Ralph Giacobbe - Crédit Suisse AG, Research Division

Justin Lake - JP Morgan Chase & Co, Research Division

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Albert J. Rice - UBS Investment Bank, Research Division

Carl R. McDonald - Citigroup Inc, Research Division

Andrew Schenker - Morgan Stanley, Research Division

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Ana Gupte - Leerink Swann LLC, Research Division

Christian Rigg - Susquehanna Financial Group, LLLP, Research Division

Operator

Ladies and gentlemen, thank you for standing by for Cigna's First Quarter 2014 Results Review. [Operator Instructions] As a reminder, ladies and gentlemen, this conference, including the question-and-answer session, is being recorded.

We'll begin by turning the conference over to Mr. Ted Detrick. Please go ahead, Mr. Detrick.

Edwin J. Detrick

Good morning, everyone, and thank you for joining today's call. I'm Ted Detrick, Vice President of Investor Relations. And joining me this morning are David Cordani, our President and Chief Executive Officer; and Tom McCarthy, Cigna's Chief Financial Officer.

In our remarks today, David and Tom will cover a number of topics, including Cigna's first quarter 2014 financial results, as well as an update on our financial outlook for full year 2014.

Now as noted in our earnings release, Cigna uses certain financial measures, which are not determined in accordance with accounting principles generally accepted in the United States, otherwise known as GAAP, when describing our financial results.

Specifically, we use the term labeled adjusted income from operations and earnings per share on the same basis as the principal measures of performance for Cigna and our business segments. And a reconciliation of these measures to the most directly comparable GAAP measure is contained in today's earnings release, which is posted in the Investor Relations section of cigna.com.

Now on our remarks today, we will be making some forward-looking statements, including statements regarding our outlook for 2014 and future performance. These statements are subject to risks and uncertainties that could cause actual results to differ materially from our current expectations. A description of the risks and uncertainties is contained in the cautionary note in today's earnings release and our most recently filed reports with the Securities and Exchange Commission.

Now before turning the call over to David, I will cover a few items pertaining to our financial results and disclosures. First, beginning this quarter, in our earnings release and quarterly financial supplement, we have combined the results of the Run-off Reinsurance, Other Operations and Corporate segments into one reporting unit called Corporate and Other Operations.

This change to simplify our reporting was enabled by Cigna's exit of the Run-off Reinsurance business in 2013. We have revised our prior period results to conform to this current presentation, and as a result of this reporting change, there is no change to our historical results.

On a separate point, please note that when we discuss the number of covered lives for our global medical customers, we will be doing so on a basis that excludes those individuals that were previously covered under Limited Benefits plans. As a reminder, we exited the Limited Benefits business as of December 31, 2013, due to ACA regulation.

And lastly, I would note that when we discuss our earnings outlook for 2014, it will be on the basis of adjusted income from operations. And in addition, our outlook for earnings per share for 2014 excludes the effects of any future capital deployment.

And on that basis, I will turn the call over to David.

David M. Cordani

Thanks, Ted. Good morning, everyone, and thank you for joining today's call.

I'll begin today with a review of our first quarter performance and highlights of our financial results. And I'll offer our perspective on how we are anticipating and adapting to the ongoing evolution of the business environment. Then I will discuss how we are developing personalized and localized solutions that improve quality and affordability through Cigna's Collaborative Care initiatives. These actions ultimately translate into differentiated value for our customers and clients and, as a result, greater value for our shareholders.

Next, Tom will provide specifics on our performance and highlight our outlook for the year before we open the floor to your questions. After that, I'll leave you with a few closing remarks.

Let's get started with some highlights. The first quarter 2014 continues our track record of strong performance and begins a new year of delivering competitively attractive financial results. Our results this quarter once again reflects strong contributions from each of our businesses.

The first quarter 2014 consolidated revenues increased to $8.5 billion. We reported adjusted income from operations for the first quarter of $501 million or $1.83 per share, which represents a per share increase of 6% over a very strong first quarter of 2013.

Turning to each of our segments. In the Global Health Care area, we continue to drive strong results across our targeted markets. Our focus on continued high-quality clinical outcomes is driving favorable medical costs for our customers and clients, with the vast majority of our clients directly benefiting from these results through our transparent funding arrangements.

These outcomes are helping us grow and deepen our relationships with more medical customers globally through a combination of retaining customers and continuing to add new ones.

In addition, our first quarter results also underscore the good progress we have made on our remediation efforts to address the claims pressure in our U.S. Seniors business.

Our Global Supplemental Benefit business continued its strong performance as we capitalize on our differentiated marketing and distribution capabilities in our targeted geographies.

In our Group Disability and Life segment, our results reflect strong performance and business growth in the midst of an improving but still challenging economic environment. Overall, this quarter's results were once again driven by our focused strategy, effective execution and differentiated capabilities that create value for Cigna's stakeholders.

Our performance for the first quarter gives us confidence that we will achieve our increased 2014 outlook.

An essential element of Cigna's sustained ability to deliver strong results in this dynamic and rapidly changing environment has been our focused strategy of Going Deep, Going Global, and Going Individual, which allows us to effectively target subsegments of the market where we can create competitively superior value for customers and clients based on our differentiated capabilities. We do this around the world, fueled by our global footprint, which is unique in our industry, with operations in more than 30 countries and jurisdictions.

As part of our Go Deep strategy, we place a continued emphasis on localizing our initiatives in our global markets, harnessing analytics and the customer insights they generate to deliver products and services that are personally relevant and adaptable to the unique needs of our target customers and clients.

We do all of this in close consultation with clients and distribution partners and in collaboration with our health care delivery partners. Cigna's ability to work collaboratively to help to improve health outcomes and reduce costs is of critical importance as many systems around the world remain challenged.

Highlight the magnitude of the opportunity in the U.S., recent studies, including those from the Institute of Medicine, have shown a majority of the patients are not receiving evidence-based clinical care. And nearly 1/3 of all medical costs are spent on unnecessary services that do not improve health outcomes.

Research also indicates that positive health outcomes are stagnating, while costs increase due to a singular focus on volume that puts tremendous pressure on the entire health care system.

At Cigna, our emphasis on collaboration and personalization of care has driven us to create a model that encourages the highest levels of quality and affordability through aligned incentives with our physician partners. Our approach combined these aligned incentives with specific actionable information and care extenders, including health coaches and case managers, to provide individualized local support.

Given our proven success in collaborative arrangements with large physician groups, in the first quarter, we announced an expansion of our value-based initiatives to better serve a large subset of our customers with high-risk conditions and complex needs, who seek care from small physician groups as well as hospital facilities.

We have also expanded our collaborative programs to include targeted specialist groups, where our focus is on 5 specialties to compromise -- comprise nearly 60% of all medical spending, such as oncology as well as obstetrics, where our advanced Healthy Pregnancy, Healthy Babies program enables more full-term natural deliveries and helps mothers and babies stay healthy during pregnancy as well as following birth.

Our latest analysis shows that our most mature Cigna Collaborative Care arrangements have delivered quality performance and total medical costs that are superior to market averages. For example, we are encouraging these urgent care facilities and offering extended office hours, which helps reduce unnecessary emergency room visits by up to 50%. We have closed 21% more guests in care, thanks in part to our embedded care coordinators who helped with prescription adherence and work to ensure continuity of care for our customers. And one of our initiatives recently demonstrated a diabetic compliance rate, which is over 20% better than market average.

Today, the scale of our efforts is significant. These programs encompass more than 1.3 million customers in 31 states, with over 63,000 doctors, including more than 24,000 primary care physicians and nearly 40,000 specialists.

Our commitment to affordable and superior health outcomes for our customers and the ongoing innovation we continue to drive is one of the key ways Cigna continues to deliver differentiated value and ensure superior competitive positioning for the future.

As we look ahead, we recognize we are operating in a dynamic global environment, characterized by existing and emerging disruptions that create formidable business challenges as well as opportunities.

As we have discussed in the past, Medicare Advantage programs will face disruption. We believe our strong U.S. Seniors footprint and leading physician engagement capabilities positions us for a long-term success in this growing segment.

While global markets remain fluid, our focused strategy, differentiated capabilities and competitively differentiated global footprint positions Cigna for sustained long-term growth. For the full year 2014, we are confident that each of our business segments will deliver continued growth.

In addition, our businesses are producing strong returns on capital, giving us the flexibility to create additional shareholder value through capital deployment opportunities. Taking these items into account, we remain committed to our long-term average annual EPS growth target of 10% to 13%.

Now to briefly summarize my remarks before turning it over to Tom. Cigna's strong financial performance during the first quarter marks another quarter of competitively attractive earnings and revenue growth and provides a strong start to 2014. Our strong balance sheet and high levels of free cash flow give us flexibility to deliver additional shareholder value.

In this disrupted environment, Cigna is leading through change, ensuring that our customers, clients and shareholders will benefit from the value of our differentiated capabilities and focused strategy execution. Within that environment, we have demonstrated proven capabilities with our physician collaboratives to deliver outstanding clinical and affordability outcomes.

And now I'll turn the call over to Tom for a more detailed look at our results and outlook. Tom?

Thomas A. McCarthy

Thanks, David. Good morning, everyone. In my remarks today, I will review Cigna's first quarter 2014 results and discuss our outlook for the full year.

We've had a very strong start to the year, driven by continued effective execution of our strategy, with significant contributions from each of our business segments.

Some key highlights from the quarter include consolidated revenues grew to $8.5 billion, driven by continued growth in our targeted markets. Consolidated earnings were $501 million. Quarterly earnings per share were $1.83, representing growth of 6% over the first quarter of 2013. And free cash flow was strong, and we returned $650 million to shareholders through share repurchases on a year-to-date basis.

Overall, the strength of our first quarter performance provides us with solid momentum for the year.

Regarding the segments, I will first comment on our Global Health Care segment. Global Health Care results were strong in both our Commercial and Seniors books of business. First quarter premium and fees for Global Health Care grew 3% to $6 billion. This reflects continued good growth in our Commercial business, partially offset by the expected reimbursement reduction in our Seniors business and our exit from the Limited Benefits business.

We ended first quarter 2014 with 14.2 million global medical customers, growing by 90,000 customers.

First quarter earnings grew 3% to $439 million and were driven by revenue growth and specialty contributions, as well as favorable medical costs across both our Commercial Employer and Seniors businesses.

Turning now to medical costs. As David indicated, we continued to improve health outcomes for the benefit of our customers, driven by engagement with physicians and value-based solutions for our customers and clients. Our commercial medical cost trend continues to be among the lowest in the industry. And given that 85% of our U.S. Commercial customers are in transparent ASO funding arrangements, our clients directly benefit from these favorable medical costs.

Regarding medical care ratios, in our U.S. Commercial Guaranteed Cost business, our first quarter 2014 medical care ratio, or MCR, was 76.1% on a reported basis or 78% excluding prior year reserve development.

Our Guaranteed Cost results reflect continued favorable medical costs within our Employer business. Overall, we are pleased with the results of our commercial risk businesses, which continued to reflect strong pricing, disciplined underwriting and continued effective medical management and physician engagement.

In our Seniors business, our first quarter MCR for Medicare Advantage was 82.7% on a reported basis or 84.1% excluding prior year reserve development. First quarter Medicare Advantage results were better than expected, with good early progress on the network and medical management actions we discussed last quarter to improve medical costs for our Seniors business.

Across our Commercial and Seniors risk books of business, our first quarter earnings included favorable prior year reserve development of $30 million after tax compared to $48 million after tax in the first quarter of 2013.

Moving to operating expenses. For the first quarter of 2014, the total Global Health Care operating expense ratio was 21.9%, which reflects the impact of the industry fee, which added 110 basis points to the expense ratio in the quarter, as well as efficiency gains and some favorable timing impacts. To recap, we've had a strong start to 2014 in our Global Health Care business.

Now I will discuss the results of our Global Supplemental Benefits business, which continues to deliver attractive growth and profitability. Premiums and fees grew 13% quarter-over-quarter for Global Supplemental. First quarter earnings were $53 million, reflecting strong customer retention, business growth and effective operating expense management with some modest claim pressure in South Korea.

For Group Disability and Life, first quarter results were strong, with premium and fee increases of 7% over first quarter 2014. First quarter earnings in our group business increased to $67 million, driven by business growth as well as lower benefit and operating expense ratios.

For our Corporate and Other Operations, results totaled to an after-tax loss of $58 million for the first quarter of 2014.

Overall, as a result of the continued effective execution of our strategy, our first quarter results reflect strong revenue and earnings contributions from each of our business segments, as well as continued significant free cash flow.

Turning to our investment portfolio. In the first quarter, we recognized net realized investment gains of $27 million after tax, coupled with a strong net investment income result. We continue to be pleased with the quality and diversification of our investment portfolio.

Now I will discuss our outlook for 2014. We expect to continue to deliver differentiated value for our customers and clients and strong financial performance for our shareholders in 2014. We continue to expect consolidated revenues to grow in the range of 4% to 7% over 2013.

Our outlook for full year 2014 consolidated adjusted income from operations is now in the range of approximately $1.93 billion to $2 billion or $7.05 to $7.35 per share. This represents an increase of $0.20 per share at the midpoint over our previous expectations. Consistent with past practice, our outlook excludes any contribution from additional capital deployment and any additional prior year reserve development.

I will now discuss the components of our 2014 outlook, starting with Global Health Care. We now expect full year Global Health Care earnings in the range of approximately $1.61 billion to $1.64 billion, an increase over our prior expectations. This increased outlook for Global Health Care primarily reflects first quarter favorable prior year reserve development, strong execution in both our Commercial Employer and Seniors businesses, with some offsets from the current outlook for our U.S. Individual business and the spending pattern of operating expenses for the remainder of the year.

I'll now summarize some of the key assumptions reflected on our Global Health Care earnings outlook for 2014, starting with our customer base. Regarding global medical customers, we continue to expect 2014 customer growth of approximately 1% to 2%.

Turning to medical costs. Our 2014 outlook continues to assume some increase in medical utilization versus current levels. For our total U.S. Commercial book of business, we continue to expect full year medical cost trend to be in the range of 5% to 6%. This strong medical cost trend result delivers value for our customers and clients across our broad array of funding types.

Turning now to our medical care ratio outlook. We are pleased with the performance of our overall Commercial Guaranteed Cost book of business, particularly the Commercial Employer component of our Guaranteed Cost book. As a result, the MCR outlook for the -- our employer book remains unchanged. We are, however, increasing our outlook for our U.S. Individual book of business MCR based on our early view of results.

Taken together, the 2014 medical care ratio for our U.S. Commercial Guaranteed Cost book of business is now in the range of 81% to 82.5%. For context, while our U.S. Individual business is growing in 2014, it will approximate 3% of enterprise revenues. As a result, we continue to expect the impact of the -- of this business will be manageable within our overall diversified portfolio. For our Seniors business, our Medicare Advantage MCR for 2014 continues to be in the range of 84% to 85%.

Regarding operating expenses for 2014, we continue to expect our total Global Health Care operating expense ratio to be in the range of 22.5% to 23.5%. We expect the operating expense favorability that we saw in the first quarter to be offset over the balance of the year by increased spending on strategic investments and some expense timing impact.

Overall, we expect full year 2014 Global Health Care earnings to be approximately $1.61 billion to $1.64 billion.

The other components of our outlook are unchanged. For our Global Supplemental Benefits business, we continue to expect strong top line growth and earnings in the range of $195 million to $215 million.

Regarding the Group Disability and Life business, we continue to expect full year 2014 earnings in the range of $305 million to $325 million.

Regarding our remaining operations, that is, Corporate and Other Operations, we continue to expect a loss of $175 million for 2014.

So all in, for full year 2014, we have increased our outlook for consolidated adjusted income from operations to a range of approximately $1.93 billion to $2 billion or $7.05 to $7.35 per share. This represents an increase of $0.20 per share at the midpoint, building on a strong 2013.

Now moving to our 2014 capital management position and outlook. Overall, we continue to have good financial flexibility. Our subsidiaries remain well capitalized and are generating significant free cash flow to the parent, with a strong return on capital [indiscernible] of our business segments.

Our capital deployment strategy and priorities have not changed. These priorities are: providing the capital to support the growth of our ongoing operations; pursuing M&A activity with a focus on acquiring capabilities and scale to further grow in our targeted areas of focus; and after considering these first 2 items, we would return capital to shareholders, primarily through share repurchase.

Regarding free cash flow, we ended the quarter with parent company cash of approximately $475 million. During the period February 7 through April 30, we repurchased 5.4 million shares of Cigna common stock for $425 million, bringing our total year-to-date share repurchase to 8 million shares for $650 million.

After considering all sources and uses of parent company cash, we now expect to have approximately $1.25 billion available for deployment during the balance of the year. This represents a $100 million increase compared to our previous capital outlook.

Overall, our financial position and capital outlook remains strong. The high returns on capital from our businesses, coupled with our strong balance sheet, means that we will continue to generate significant free cash flow to deploy for the benefit of the shareholders.

Now to recap, our first quarter 2014 consolidated results reflect the strength of our diversified portfolio of global businesses and continued effective execution of our focused strategy. The fundamentals in our businesses remains strong, as evidenced by our first quarter results, which reflected attractive growth and revenue earnings, favorable medical costs that directly benefit our customers and clients and continued strong free cash flow.

Based on the strength of these results, we are confident in our ability to achieve our increased full year 2014 earnings outlook.

With that, we will turn it over to the operator for the Q&A portion of the call.

Question-and-Answer Session

Operator

[Operator Instructions] Our first question comes from Scott Fidel with Deutsche Bank.

Scott J. Fidel - Deutsche Bank AG, Research Division

First question, just relative to the improved HealthSpring results in the first quarter, can you talk about how that broke down between seeing less claim severity possibly relative to the back half of the year, what you're seeing just in terms of general utilization trends at MA and then compare that relative to the actual company-specific initiative that you put in place to help improve results? So really looking at sort of how much was the broader environment as compared to the company-specific initiatives that you've now been putting in place.

David M. Cordani

It's David. I'll give you a little color there. First, to headline, we're pleased with the results and the progress that the first quarter demonstrated. When we take a look at the results to highlight a few items, one, clearly, the fourth quarter of last year matured favorably versus expectations. So that contributed to reported results, but it also contributed to a jump-off. I'll come back to that in a moment. Secondly, we're seeing some positive impact in the first quarter relative to our own performance from the contributions of the benefit positioning we've put in place for 2014. And third, specifically, we are seeing an impact of some of the target remediation efforts we embarked upon, whether it's the targeted recontracting in key markets, some network optimization or some additional focused medical management activity. So I would suggest that from our point of view, we're pleased with the results, and the results we're demonstrating here are primarily driven by own actions. Stepping back, a little bit more color. Year-over-year, what we know is the flu season was less severe in the first quarter of '14 than it was in the first quarter of '13. So that's an industry event. And finally, at least from our point of view, given the markets we operate in, as best we can understand, we did a de minimis impact to the weather from an overall operation. So maybe a little bit less utilization in the first quarter tied to the flu. The rest of it is broadly driven by some of our actions.

Scott J. Fidel - Deutsche Bank AG, Research Division

Okay, got it. Then just the follow-up question, just following up on Tom highlighting that you're increasing the MLR expectations for the Individual business. Just if you can walk through some more color on that and just interested in how much of that is affected by what you're seeing on the exchange and expectations in terms of profitability there as compared to in the existing Individual business and, I guess, relative to some of the unexpected policy changes that developed over 2014.

Thomas A. McCarthy

Thanks, Scott. It's Tom. First, before we get to the specifics under Individual, I do want to step back and remind you that we're still very happy with the overall fundamentals of our risk business. They've been strong in the quarter and have been for some time reflecting the disciplined pricing and underwriting and strong clinical management and physician engagement capabilities. And in case you missed it, we are not changing the MCR outlook for our Employer business. All of the change in our Guaranteed Cost to MCR outlook does relate to Individual. A few points to make here. Our early claim experience for this business and a cautious view on recoveries from risk adjusters in risk quarters has caused us to increase our view of the Individual MCR for the full year. So that really is the driver, some caution seen in the early claims experience and uncertainty about what the future looks like. I'd also point out to you that while Individual is a small portion of our overall business, it represents a growing share of our Guaranteed Cost business. It's about -- now about 25% to 30% of our total Guaranteed Cost business. So again, the uncertainty on the MCR outlook and the growing share of the overall Guaranteed Cost book is what's caused us to increase the GC MCR. And I would also remind you that in the context of our overall company, Individual is still small, representing about 3% of our total revenues.

Scott J. Fidel - Deutsche Bank AG, Research Division

Okay. And, Tom, just to clarify, the early experience where you're seeing some of these higher claims, that's on the new exchange lives that are coming in?

Thomas A. McCarthy

I'd say it's the new ACA lives, so both ACI-compliant policies on exchange and off exchange.

Operator

The next question comes from Josh Raskin with Barclays.

Joshua R. Raskin - Barclays Capital, Research Division

Just, Tom, could you quantify the favorable operating expense? I think you mentioned the timing impact. Just want to see exactly what that was and what the impact on the quarter was relative to expectation.

Thomas A. McCarthy

Yes, Josh. I don't think I want to get into the specific timing. We have a few things going on in expenses in the quarter. First, we kind of have the ramp-up over the year of strategic spend. So I think you know we're launching our duals project in Illinois. We've got the India launch in Global Sup. We also have timing of some IT portfolio spend and the -- some specific timing on hiring ramp-up that we might have over the course of the year. If you look at the impact of the favorable results in the quarter, it's pretty evenly mixed between the medical cost, the expense savings and the continued strong revenue contributions from our businesses.

Joshua R. Raskin - Barclays Capital, Research Division

Okay, [indiscernible] quantification. And then could you talk a little about private exchanges? I mean, did you guys see anything in terms of net gains or losses in the first quarter in 2014, any of your customers sort of discussing the opportunities for private exchanges? I know you guys have your own initiatives in-house? I'm just curious, did you -- were you guys sort of net winners or losers on private exchanges? And where do you think that goes this year?

David M. Cordani

Josh, it's David. Well, let me give you a little color. First, just to frame our view of the private exchanges and then I'll tell -- I'll get right to your -- the heart of your question. As we've discussed in the past, we view that the private exchange environment is still in the early phases of adoption and clearly may create a very attractive sustainable marketplace for time to come, leveraging some retail purchasing environment and transparency. A little color to think about in terms of as you know, there's a lot of different private exchange models. So retiree versus active, single carrier versus multi-carrier, highly localized versus broader rating areas, employer remaining involved versus employer not remaining involved and lastly, pooled funding versus transparent funding. To date, our experience is around our participation in many of those models, including our own proprietary exchange. Today, our target clients have continued to reinforce a desire to stay engaged, have more personalization and localization and maintain more transparent funding arrangements. The net of all of that, through our experience, has been de minimis, meaning puts and takes, wins and losses, relatively small volumes and a relatively small net movement within the portfolio. Important in your question is around dialogue. There's a lot of dialogue because this is a new mechanism. So clients and prospects are wanting to learn more in terms of what are the value creators both in year 1 as well as sustainability of the value creators, and we're actively engaged in those conversations. But I think the important headline is heretofore de minimis impact to our business in terms of the net puts and takes.

Joshua R. Raskin - Barclays Capital, Research Division

And, David, is there actually been more specific, I was looking more on the active employees. So I don't know if there's sort of puts and takes, you're doing better on one, retiree versus active? Is there a difference between those 2 platforms?

David M. Cordani

Yes, I appreciate the clarification. Net-net, no. The aggregate puts and takes for our organization, again, whether I look at the retiree environment, whether I look at the active medical, whether I look at the specialty components, it's all netting to a very small number right now. Having said that from my comments, you should take away that we're active in engaging in multiple as the models, and we're active in kind of exploring additional value creators for the benefit of clients and customers. But to date, both active and retiree is relatively small.

Operator

The next question comes from Ralph Giacobbe with Crédit Suisse.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Just want to go back, the 100 basis point increase in Guaranteed Cost MLR seems pretty large in the context of how small your just sort of Individual book is. And if it is coming from exchange, it would obviously suggest significantly higher costs there. So hoping you can give us more details on the risk of business that you brought on or the people that are signing up much sicker than you would have expected, age cohorts, if you have that detail or if it's your sense that across the board, just the population that's on the exchanges just were soft across the board relative to just your existing book.

David M. Cordani

Ralph, it's David. Let me try to give you a little bit of color. Just 2 sets of comments: one, put the size in context; two, the early experience. So when you think about the size, as Tom referenced earlier, is Guaranteed Cost represents a smaller portion of our overall portfolio. And we look at Guaranteed Cost going into 2014. As you know, we have the impact in terms of lives of running off the Limited Benefit business. So the aggregate number of lives and Guaranteed Cost decreases and then the growth in the Individual business. And Tom referenced, while the Individual business is about 3% of our enterprise revenue, it's in the 25% range of the guaranteed cost environment. As it relates to the early experience, a comment in terms of 2 waves of buyers that we see: the early initial buyer group and then the latter surge that the press talked about in terms of wave 1. What we know is that in the early buyer group, on average, that buyer group was older than our expectations. They bought a bit richer benefit plan than our expectations, so what was still the nucleus, but it's a bit richer benefit plan. And their medical utilization in the first month or so of experience was much higher than any of the -- our book of business norms, including some categories of severity around that. What we also know is that in that second wave or the latter surge of buyers, that population is younger than the initial population and more in line with our age expectations. Two, they bought leaner benefits on average than the first group and a bit more in line with our expectations. What we don't know is what the utilization is because they just signed up very recently. And as Tom pointed out, within our outlook, we took into consideration our early experiential set and projected that forward with some reasonability in terms of our overall outlook, and the most important thing here is that it's manageable in the aggregate context of our overall organization.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Okay, okay. That's helpful. And then want to go to sort of hep C cost in the quarter. I think you have some details there what it was last year, what are your projections, I guess, around that for this year and then maybe how you're attempting to control it.

David M. Cordani

Sure. Just a little context and then specific to my experience. First, I think it's important to recognize that specialty pharmaceutical costs have been and continued to be a major trend and cost driver. As far as our internal processes, we project specific medical trend for specialty pharmacy, taking into consideration what we know about existing drugs, utilization patterns and, importantly, what's in the emerging pipeline. And while Sovaldi was not specifically broken out as a trend item for Sovaldi, our experience in the first quarter suggested our trend assumption for specialty pharmacy is in line with our overall aggregate experience, including the Hep C experience. Lastly, very important to note from our point of view, to achieve the right AAA outcome of clinical quality, service quality and affordability, you have to be able to manage the medical experience, the pharmacy experience and the specialty pharmacy experience, so the overall whole person could be managed with the right physician engagement. Specific to our financial results, when you think about the guaranteed cost in the Medicare population to the nearest $10 million or so in the first quarter, it's about $10 million for us, the rate of growth was accelerating throughout the quarter, and we've taken that into consideration, our full year outlook that Tom made reference to and still is considered in our medical trend outlook, which has not changed at this point in time.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Okay, that's helpful. Just on the ASO side, though, you customers there, what can you do, I guess, to control it at that point from that side of the business as oppose to an issue for you all, specifically?

David M. Cordani

Sure, and I appreciate the clarification. Important to note that in terms of our clinical programs, clinical engagement within our company, in general, we don't differentiate the way we actively engage physicians for an ASO customer versus an experienced rated person with a guaranteed cost customer. The clinical guidelines, clinical efficacy guide set. So the same level of active management with the physicians around that patient population, understanding medication compliance, alternative treatment categories and active management take place. And again, to date, while an acceleration of cost specific to that drug, our overall specialty pharmaceutical trend is, generally speaking, in line with our expectations. And our overall medical trend, as Tom made reference to, remains in line with our expectations. So the same active management takes place regardless whether or not it's an ASO client, a shared risk client or a guaranteed cost client.

Operator

The next question comes from Justin Lake with JP Morgan Chase.

Justin Lake - JP Morgan Chase & Co, Research Division

First, a follow-up on the Medicare Advantage book. Looking ahead to 2015 bids in June, can you tell us if you expect to try to bid back to mid-single-digit margin target that you've typically discussed for the current low-single-digit you're expecting for 2014?

David M. Cordani

Justin, it's David. Macro level, not helpful to publicly discuss our bid strategy and margin objectives. To give you a little bit more color than that, first, stating the obvious, the improvement we're experiencing in the first quarter of medical cost performance, as well as the favorable maturation of the fourth quarter, is obviously directionally helpful in our journey. Secondly, as you referenced, our long-term margin objectives are not the margin performance that we are experiencing in 2014. That's clear. So as we set our expectations, you should expect it on a, obviously, market-by-market and on a very precise basis to seek to ensure that we are positioning a benefit program that is differentiated and attractive, while balancing a fair return, and we would like to see a step forward in terms of our performance as we go into '15 and then '16 and beyond. So, directionally, yes, but as for specifics, we're not going to comment in terms of what our margins objectives are for 2015 at this point.

Justin Lake - JP Morgan Chase & Co, Research Division

Great, that's helpful. And then just a couple more follow-ups on this Individual segment. First, it sounds like you guys are taking a cautious look at the 3Rs and specifically, Tom, you talked to the -- I want to ask you about the risk corridors. Given the government discussion of budget neutrality here, can you tell us whether you feel comfortable booking a receivable in places where you are into the risk corridor because you have negative margins?

Thomas A. McCarthy

Yes, Justin, again, as you kind of did pick up, we are taking a cautious view on the 3Rs. Now that specific accounting question, we'll get to that someday. But right now we haven't incorporated any impact for risk adjusters or risk corridors and given the uncertainty and the dynamics, we're not really expecting any significant impacts for the year. So I don't think that's going to be a key issue.

Justin Lake - JP Morgan Chase & Co, Research Division

And so what kind of margins are you expecting in Individual?

Thomas A. McCarthy

Justin, your question, for 2014 or long term?

Justin Lake - JP Morgan Chase & Co, Research Division

No, '14, I'm sorry. So what are you now kind of embedding in guidance for individual book?

David M. Cordani

Justin, we didn't obviously break out the margin specifically. To give you a little bit more color, as you recall from our -- let's go back to the strategic positioning here. We said we would take a very focused position, we've positioned ourselves in 5 states, in a limited number of markets in those states. We suggest very consistently that we did not expect that this will be a profit driver or a positive profit contributor before the year started. That's where we stand today, even acknowledging the bit of margin pressure that Tom made reference to. And we think it's appropriate at this point in time to take a cautious view of the component of the 3Rs, which may present some softening opportunity on a go-forward basis, but our current first quarter performance does not contemplate that. And important part is how do we position ourselves for 2015 as we go forward. As we sit here today, our bias is to extend into a few additional markets, we know which markets those are, we haven't made the final calls there, but we have a high level of engagement with physician and hospital partners who would like that expansion, and we're making that assessment. So clearly, taking into consideration our current experience, we still have a bias to extend, but we haven't declared that at this point in time.

Justin Lake - JP Morgan Chase & Co, Research Division

I'm sorry, just one clarification. You're expecting to lose money in the Individual market for 2014?

David M. Cordani

It is correct, and that is consistent with our expectations before the year started.

Operator

The next question comes from Kevin Fischbeck with Bank of America Merrill Lynch.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

I just wanted to understand the guidance a little more. It seems like the raise in the guidance on the commercial side is kind of less than the PPD that you saw in the quarter. And if you adding in the share repo in PPD, the guidance raise looks to be entirely related to value and there was additional outperformance in the quarter. And, guess, maybe Individual is just a little bit worse, but just trying to understand what the delta is more specifically.

Thomas A. McCarthy

Sure, Kevin, it's Tom. So first, again, stepping back, there are a lot of positives in the first quarter, and we do expect they will continue to provide positive momentum for the year. We have continued solid execution of our strategy, we have the good growth in our targeted markets, we have strong medical cost management, leading to lower-than-expected medical cost in both commercial and seniors and disciplined expense management, resulting in favorable operating expense. So all good things. That said, it is early in the year. And while we're pleased with the positive result for medical cost in the quarter, we're really not ready to project that, that will continue favorable for the full year. Our outlook does, as we've talked about, include some caution regarding Individual results as the early stages of that market are unfolding. And as we've also referenced, we have some timing impact to offset in the first quarter operating expense favorability, including a ramp up of strategic spending over the course of the year. So on balance, that lets us do the outlook we've offered. And overall, we're really pleased with the start for the year and confident in that full-year outlook.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

And I guess, maybe, in response to one of the questions earlier, David mentioned that the favorable development in the MA book kind of give you a better starting off point than maybe you thought kind of entering the year. Can you just go back to what you now know about Q4? Talk about what really -- what is the issue and how much of a variance it was versus your expectations as you enter 2014?

David M. Cordani

Sure, it's David. So a little bit more color there. What we did see is, as we play back the tape, in the latter part of Q3, we saw some elevation in cost. We saw that play through in the early portion of Q4, and we represented that as we went through the year-end activity. The good news is that as the latter part of Q4's claim experience matured, that matured more favorably than that spike that transpired in the latter part of Q3 and the early part of Q4. Secondly, that abatement continued into the first quarter of 2014. And finally, some of the very targeted actions that we begin to execute, whether they were re-contracting, network optimization, also started to make contributions in the first quarter. All net-net positives. And as Tom said, at this point, we're not ready to declare kind of a full projection on a go-forward basis. We're really pleased with the jump off, we're really pleased with the favorable development in the fourth quarter and we're very pleased with the net performance in the first quarter.

Operator

The next question comes from A.J. Rice and with UBS.

Albert J. Rice - UBS Investment Bank, Research Division

First of all, if I just might ask for an update on with respect to the PBM, the integration with Catamaran, are you -- how's that -- any update on that and where you're at relative to the -- getting ready for the selling season this year and what are your expectations for the PBM selling season?

David M. Cordani

A.J., it's David. Just a moment of backdrop and then specific to your question. Our PBM is well-positioned, strong performing assets. We've been able to demonstrate that our approach to the market around integration, medical and pharmacy, delivers a very positive, both clinical outcomes, service outcome and affordability. The actions we embarked upon to further strengthen our cost of goods sold, secure an innovative technology platform and accelerate our innovation cycle, because of that, are going to be net adds to that. The headline is we're tracking very positively to our expectations. Secondly, good marketplace receptivity from clients in the overall marketplace, relative to both our current value proposition, as well as our enhanced value proposition as we see in the marketplace. You'll note that we had some slight growth in our pharmacy business in terms of net covered lives, again, which we're pleased with. But we're optimistic that, that momentum, obviously, continues on an go-forward basis, and we're on track with our expectations.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. And I might just come back to the Sovaldi question in a different way. I guess, with your ASO membership, obviously, they're holding that cost themselves, you're working whether to try to mitigate that. At a time when people out there telling them, " Hey, join the private exchange, give up that, go back to fully insured." Is -- give us some flavor for whether this is creating confusion among that self-insured base at this point. Are people -- or is it creating any kind of disruption that might further that push to private exchanges from your perspective?

David M. Cordani

A.J., it's David. So taking the intent of your relative to using Sovaldi as a cost driver and a cost driver putting affordability pressure. At the end of the day, I think you hit a really important macro theme here, which is there's a fundamental affordability challenge societally, whether the client or an employer is financing it, an individual is financing it and as we see whether or not governmental entities are financing it. So what we see, to your point, is clients are more open and active than ever to explore solutions that can demonstrate really significant value in terms of improving clinical quality and more sustainability of cost. To date, as we've demonstrated, we've been quite successful in terms of being consultative, working to put the right benefit design, incentive and engagement capabilities in place, wellness programs, specialty programs, network designed with our collaboratives and then offer a variety of funding alternatives. So you should envision, A.J., that in many cases, our consultative selling-- sales force offers more than one way to finance a benefit program and consults with our clients to be able to make a choice. We think more of that consultation will take place in the future versus less, and employers will continue to choose what works best for them. What I don't think is, I don't think Sovaldi or Hep C, as an example, is a binary trigger to make a client do something very different with their benefit programs. It raises awareness that doing the same thing over and over, if you're not getting a positive result, is probably not going to yield a positive result next year. And we're pleased with the fact that our clinical quality is strong, we've yet to deliver another year of outstanding medical cost performance relative to any industry benchmark, and that comes from being consultative, engaging the client, working differently with their individual customers and working differently with the physicians, and we think more of that will come in the future.

Operator

The next question comes from Carl McDonald Citigroup.

Carl R. McDonald - Citigroup Inc, Research Division

First question is on the guaranteed cost business. If I look at the enrollment and back out the individual growth, it looks like the, we'll call them, group guaranteed cost, was down about 10% sequentially in the first quarter. So can you just walk through what you're seeing there, if that's aggressive pricing, if that's ASO conversions, and any other factor?

David M. Cordani

It's David. Just at a more macro level, as I referenced previously, when you look at the year-over-year, first and foremost, of the guaranteed cost block, historically, it's been a smaller portion of our overall portfolio of businesses, 8% to 10% of our covered lives. Two, as we step into 2014, we're rolling off the Limited Benefit business, which was a guaranteed cost portion of the pool. We have a, I'll call it, a well-performing employer book, as Tom made reference to, book of business, and then we have a growing individual block of business. So that's the guaranteed cost, if you will, from a slide standpoint. Overall marketplace, we continue to see a high level of receptivity for some of the more transparent funding alternatives within the employer space. ASO, ASO with Stop Loss, assured returns. And then finally, importantly, in a segment that is historically valued, both guaranteed costs and otherwise, what we call the Select Segment, employers between 51 and 250 employees, we regularly offer guaranteed cost side-by-side with ASO Stop Loss, and we continue to be successful there with both programs. However, a bit greater than 50% of the new business sales there and ramping up beyond that are ASO Stop Loss. So market trend, more transparency. Two, changing our book of business with the run-off of the limited benefit business, replaced with growth of the individual block of business, and a, I'll call it, a somewhat stable, in terms of aggregate lives, well-performing group insurance block of business that we have in our portfolio today.

Thomas A. McCarthy

And the dynamics that have been impacting our guaranteed cost business, are as David has suggested, the dynamics of which programs customers are choosing. Keep in mind, we don't have really any play in the small group market segment, which seems to be where the commentary around intense price competition has been coming up. And the segments we're playing in, the pricing environment continues to be pretty rational.

Carl R. McDonald - Citigroup Inc, Research Division

All right. So my down 10% figure adjusted for the Limited Benefits. Taking from your comments that you're saying most of it is conversions to ASO, then?

Thomas A. McCarthy

That's in the ballpark. Conversions is a tricky word, right? I can't -- this is a segment that has -- the lower end of this segment has a lot of turnover, so I'm not sure whether it's all conversions from risk to customer to ASO in that segment. It's more, as the new customers are coming in, they tend to be buying ASO programs more than they have in the past.

Carl R. McDonald - Citigroup Inc, Research Division

And then the other question was just, if I take -- again, focusing on health care, if I take out the guaranteed cost in the Medicare component, it looks like the loss ratio on all of the other products experienced, rated, Stop Loss, et cetera, was about 500 basis points better, sequentially. The fourth quarter loss ratio was inflated versus what you've been historically. But just the question is, is the first quarter loss ratio in the other segments a sustainable number for the rest of the year?

David M. Cordani

Yes, again, Carl, as we talked about last quarter, there's a lot of things in that residual component of loss ratio calculation. But I would highlight, as we said last quarter, the results last quarter were somewhat of an anomaly, and that all the businesses reported on in that group of products have been performing pretty well for us. So I'd say, the performance we've seen in the quarter, we'd expect to be consistent. Whether that ratio moves around, as mix of business changes, it's a little hard to know how that would play out over the course of the year, but we were happy with and continue to see good performance in those other product lines.

Operator

The next question comes from Andy Schenker with Morgan Stanley.

Andrew Schenker - Morgan Stanley, Research Division

So your India [indiscernible] officially began to find products in the country recently. Maybe, how is that relationship is developing? Maybe how should we think about the long-term earnings contribution from the interim, national markets like India, Turkey, et cetera. Do you continue evaluating new market entries, or are you still focused on increasing footprint penetration in your existing market?

David M. Cordani

Andy, it's David. So relative to the global marketplace, thinking about 2 major marketplaces we compete in, and then I'll address India, Turkey and the like. One is, we call it, the Global Employer marketplace. Historically, for expats, for corporations, IGOs, NGOs, that business, we currently serve truly globally around the world, and we have customers, individuals we service across the globe, that business continues to grow very attractively. We have the largest delivery network in the world in terms of supporting those individuals on behalf of our clients, and we'll continue to grow that. Secondly, within that business, increasingly, we're hearing from some clients within key geographies where they have critical mass, a desire for some, I'll call it, health improvement and productivity improvement programs. So think about the employer businesses global across all geographies. The business that you're referencing is our direct individual supplemental benefit business. Two markets that we sought to enter strategically were the ones you referenced, Turkey and India. Turkey, we are successfully selling and has been successfully selling now for some time. And we're pleased with the direction of trajectory there. India, very exciting. We completed all the regulatory reviews and approvals, and in the first quarter, we actually began selling products and services there. We view India as a long-term attractive, very attractive growth opportunity, both for the individual business, as well as for clinical services. For example, India has the highest percentage of diabetics in the world and it is a major burden for the social mandate and were viewed as being part of the solution within that. Finally, as it relates to additional geographies, there are some additional geographies that are attractive to us, but most importantly, within our portfolio today, our existing markets, plus India and Turkey, present a very nice growth profile, and we will systematically identify new markets that are attractive to enter as we go forward over the next few years.

Andrew Schenker - Morgan Stanley, Research Division

Great. And then just a follow-up on something else here I have to clarify. What are you now expecting for exchange enrollment, including the March and April surge we saw, and how does that compare to your expectations? Are you now expecting exchange enrollment to be kind of above your initial expectation?

Thomas A. McCarthy

So Andy, it's Tom. I'll give you some context on the overall Individual block. So by the end of the year, by the end of 2014, we'd expect to have about 290,000 customers in the Individual segment. About 40% of those customers will be on ACA policy and about 60% will be of the legacy non-ACA policy. So a combination of early renewals or keep your plan states. And of the ACA policies, we'd expect about 60% to be on the exchange and 40% to be off the exchange.

Andrew Schenker - Morgan Stanley, Research Division

And how does that compare to your kind of original expectations heading into the year?

Thomas A. McCarthy

A little bit.

Operator

The next question comes from Peter Costa with Wells Fargo Securities.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Looking at the reinsurance and recoverables, it was up from $150 million both sequentially and year-over-year to $250 million. So that really sort of helped out your performance a little bit. Can you talk about why that improved, why you have so much more in reinsurance recoverables. I know you said you didn't book anything for risk adjusters or risk corridors, so I'm kind of curious what drove that.

Thomas A. McCarthy

That reinsurance recoverable -- this is Tom, that reinsurance recoverable number is a function of some of the business we seeded off. And you might recall the run off reinsurance business has some market value sensitivity to the reported financial statements. So that really is largely just readjusting the seeded amounts based on market performance. There's really nothing going on there. And the impact of the 3Rs on that is nonexistent at this point.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Okay. And that was tied to the medical claims payables. So you're still leaving the runoff reinsurance have impacted that? Just from the claims payables line stated $1.9 billion.

Thomas A. McCarthy

I thought you were asking specifically about reinsurance. So medical claims payable, again, that's just regular operating activity. There's really medical reserves are up at the end of the quarter, no surprises in that result.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Actually, there were $1.9 billion, both sequentially and...

Thomas A. McCarthy

You take that to another digit, it would actually be up, it's actually up almost $100 million, I guess, if you take it the one to the next digit. So again, so that means it was like 1850 going to 1950 or in that ballpark. So again, if you look at the days claims payable, they're up. If you look at the -- if you had the specifics of the dollar balance are up, there's no issues in the -- we still feel very comfortable with our reserve position in all of our businesses.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Okay. And then can you talk a little bit about your 2015 selling season, and what you think will be different from 2015 relative to 2014 in terms of the number of clients available or the number of the business moving and what clients are looking for at this point?

David M. Cordani

Peter, it's David. Early in the cycle, so I'll give you some directional comments. As it relates to the 2015 selling season, by way of purchasing dynamic, we continue to see those clients that we both serve today, as well as prospects, very aggressively addressing incentive and engagement-base program designs. That could be a coinsurance program with an incentive pool attached to it. It could be a consumer-directed program, but a whole variety of way to use incentive and engagement-based tools. Secondly, much more active utilization within consideration around health coaching and advocacy, health advocacy services, including an increasing appetite for on-site health coaches, something we do very well. And then third major theme is in terms of increase in specialty carve-in demand. So some of the themes that we put specialty carve-outs, we see some direction in terms of more integration. As it relates to volume from a pipeline, early indicators relative to the, we typically call the national account pipeline, let me just define that, because we define it differently. So it will be commercial employers with 5,000 or more employees, that's the way we define it, it's a little bit different than the market, that are multistate. Early indications for that pipeline is inbound opportunities, outbound opportunities, no major macro change in pattern there, decision-making cycle, a little longer because of the complexity of some of the benefit attributes I just talked about today, and we would expect to have a net market competitive positive performance as our strategic direction go into 2015.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

And what about on the smaller group and select size? Do you see them looking more at public options and things like that or exchange options?

David M. Cordani

Yes, It's quite early to talk about 2015 for the smaller group. Remember, we don't play under 50. In the Select segment, which is 51 to 250, we're in the heart of the 2014 selling season everyday, and will be through the second quarter and the third quarter. As it relates to the makeup of our book of business, we have a high percentage, even in that book of business of clients who value what I referenced before. They're actively engaged, using incentives, we have examples of 75 and 100, 125 [ph] employers that are using on-site biometrics, health engagement, et cetera. So we don't see dramatically a lot of demand for public exchange within our target subsegment there. But important to note, we're in the heart of the 2014 selling season within that portfolio as we sit here today.

Operator

The next question comes from Ana Gupte with Leerink.

Ana Gupte - Leerink Swann LLC, Research Division

Yes, just to follow-up on some of the question on your commercial book of business. It looks like the big growth right now is happening in Select, where you've grown almost 15% on membership, Stop Loss is growing 20%, I'm assuming there's a lot of correlation between that. And finally, in Individual, where you're talking about, this year at least, having some headwinds to profitability. The rest of it looks flattish, which is actually better than maybe some of the competitors there are reporting in some cases. So if you look at that book and the growth rates, how do you think about de-risking in and do you expect to keep that level of growth within those markets, specifically retention and growth in select? And then how would you grow your Individual book by making it more profitable?

David M. Cordani

Ana, it's David. I think overall, you painted a picture of the various segments. So starting where you started. Our Select segment, which is, again, employers with 51 to 250 employees has been and continues to be a very attractive growth segment for us. Within that segment, we sell guarantee cost and we sell ASO with Stop Loss. Typically, in a highly bundled fashion with our specialty products and services. And we're somewhat agnostic, meaning in terms of providing the choices for clients and giving them the financing options that works best for them. Our growth in that segment, we're very excited about and pleased with, comes in an environment where our team is consultative and working to design benefits that are positioned for those specific employers. And historically, this segment has not have a lot of choice. This segment has had prepackaged guaranteed cost alternatives only and is tired of confronting an environment of a sustainable medical cost trends. So we see this as a continued growth segment for us and it's one we're quite excited about and we're comfortable with the risk profile here. As it relates to the next segment that you inferred about but didn't speak specifically about, the regional segment, which we define as a large segment of our book, so 251 to 5,000 employees, I mean, large single-state employees. That business has grown and grown competitively and attractively year-on-year, and we expect that throughout the residual portion of the year, we'll demonstrate some growth there. Finally, to your point, in the Individual segment, we have a little higher growth, a little higher growth than we expected. It is not profitable. We did not expect for it to be profitable in the first year, very important. We did not plan for it to be profitable and we view that, that was manageable within our portfolio, and we expect to, on a very pinpointed basis, channel the market learnings and the evolution of the market as we position that portfolio for 2015. So net-net, for the enterprise as a whole, we actually like our positioning coming out of the first quarter this year with good growth, good revenue performance, good specialty penetration, strong medical cost performance that positions us for this year, and then stepping into 2015.

Ana Gupte - Leerink Swann LLC, Research Division

So what you're saying is that your competitive strength continues and the likelihood of any shift to public exchanges, particularly into the lower end of the market is at this point?

David M. Cordani

Yes. And Ana, I would just pinpoint 2 comments. Again, knowing that we don't play in the under 50 market; and two, the target clients on a very specific basis. So I'm not speaking for the entire client universe between 50 and 250. I'm speaking towards, in our core markets and for the clients we are targeting, we continue to see high receptivity for the active engagement programs as evidenced by our growth, as evidenced the our strong net retention, as evidenced by our market-leading medical cost trend, and within that, as long as we continue to deliver value, we see good opportunities in the future.

Ana Gupte - Leerink Swann LLC, Research Division

Now on the International, which is the other growth segment, and I think you talked about Turkey and India. But just on the core growth, it looks like the U.S., both Korea and the China JV you are growing, overall you had good revenue growth, you saw some margin compression, I think you made some commentary about claims cost in Korea ticking up and some retention initiatives and so on. And you alluded to some pressure in the fourth quarter of '13. Is this a structural margin compression story, or is there any pricing or other action you can take to get the margins back up? And would the normalized growth rate of 7% to 14% that you've guided to potentially go at the upper end or even higher, 2015 and beyond.

Thomas A. McCarthy

And it's Tom. So first, again, stepping back, we continue to get good results in our Global Supplemental Benefits business. We have great revenue growth in the quarter, very consistent with our expectations. And the earnings in the quarter were actually also consistent with our expectations. We have a little bit of a tough quarter-over-quarter comparison, given the strong results we reported in 2013. But this business is performing as we'd expected. We're continuing to make investments to expand the business. We already talked about India, we've got some investments in new distribution sources. You pointed out Korea. Our Korean operations continued to perform pretty well. We did have that higher seasonal claim pattern that we report at the end of 2013 that did continue into early 2014, but now it's back to normal levels at the end of March. So I think, overall, we're pretty happy with the positioning for this segment and comfortable that it's going to be a good segment for us with fast growth.

Operator

The final question comes from Chris Rigg with Susquehanna Financial Group.

Christian Rigg - Susquehanna Financial Group, LLLP, Research Division

Just, David, you had talked about sort of 2 waves of sign-ups with regard to the ACA's compliant plans. Can you give us sort of a sense of the pace of the sign-ups when you sort of finished up with the wave 1 and then moved into the wave 2, just might help with some context around the change in the MR outlook.

David M. Cordani

Sure, Chris. As I think about the wave 1 of business that came on, known and is being serviced in the first part of the quarter. So came through, obviously, the entire fourth quarter of last year, but the wave that we were servicing in the month of January. Then think about a pretty meaningful low in terms of the wave, obviously, lives are coming on with a significant surge coming in the March and latter part of March timeframe, whereby, we know the profile of those individuals, as I referenced, younger, than the original group. We know the benefits they purchase by medical category, leaner. We know some kind of risk characteristics to that group better than the first group. What we don't know is the utilization pattern in the first quarter results we're talking about here. But we would point toward a better risk profile than the first group. So think about bucket 1 on-board, being serviced, throughout the fourth quarter, small, additional growth throughout the quarter, and then a big surge toward the latter part of the quarter enrolling literally at the end of the quarter or going into the April timeframe

Operator

I will now turn the call over to David Cordani for closing remarks.

David M. Cordani

Thanks. To conclude, I'd like to emphasize a few key points from our discussion this morning. Cigna's first quarter results were strong and with meaningful contributions from each of our business segments. Our results are driven by the continued effective execution of our focused strategy, which reflects the commitment and dedication of our more than 35,000 colleagues working around the world. By aligning our capabilities with the goals of our customers and clients, we are improving the health, well-being and sense of security of the people we serve around the globe. We're confident in achieving our increased outlook for the full year of 2014, and we remain committed to achieving our long-term average EPS growth of 10% to 13%.

Thank you for joining us this morning and for your continued interest in Cigna, and we look forward to continuing our discussions in the future.

Operator

Ladies and gentlemen, this concludes Cigna's first quarter 2014 results review. Cigna Investor Relations will be available to respond to additional questions shortly. A recording of this conference will be available for 10 business days following this call. You may access the recorded conference by dialing 1 (800) 834-5622 or 1 (402) 280-1650. No passcode is required. Thank you for participating. We will now disconnect.

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