10-K 1 d10k.htm FORM 10-K Form 10-K

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

 

FORM 10-K

 

(Mark One)

x

ANNUAL REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE

SECURITIES EXCHANGE ACT OF 1934

 

For the fiscal year ended December 31, 2004

OR

¨

TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE

SECURITIES EXCHANGE ACT OF 1934

 

For the transition period from                      to                     

 

Commission file number 001-16751

 

WELLPOINT, INC.

(Exact name of registrant as specified in its charter)

 

Indiana   35-2145715
(State or other jurisdiction of   (I.R.S. Employer Identification No.)
incorporation or organization)    
120 Monument Circle    
Indianapolis, Indiana   46204
(Address of principal executive offices)   (Zip Code)

 

Registrant’s telephone number, including area code: (317) 488-6000

 

Securities registered pursuant to Section 12(b) of the Act:

 

Title of each class


 

Name of each exchange on which registered


Common Stock, Par Value $0.01

  New York Stock Exchange

 

Securities registered pursuant to Section 12(g) of the Act: NONE

 

Indicate by check mark whether the Registrant (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past 90 days.  Yes  x  No  ¨

 

Indicate by check mark if disclosure of delinquent filers pursuant to Item 405 of Regulation S-K is not contained herein, and will not be contained, to the best of Registrant’s knowledge, in definitive proxy or information statements incorporated by reference in Part III of this Form 10-K or any amendment to this Form 10-K.  ¨

 

Indicate by check mark whether the Registrant is an accelerated filer (as defined in Rule 12b-2 of the Act).  Yes  x  No  ¨

 

The aggregate market value of the voting and non-voting common equity held by non-affiliates of the Registrant (assuming solely for the purposes of this calculation that all Directors and executive officers of the Registrant are “affiliates”) as of June 30, 2004 was approximately $12,325,389,690.

 

As of March 1, 2005, 304,985,533 shares of the Registrant’s Common Stock were outstanding.

 

DOCUMENTS INCORPORATED BY REFERENCE

 

Portions of the following document have been incorporated by reference into this Annual Report on Form 10-K:

 

IDENTITY OF DOCUMENT

  PART OF FORM 10-K INTO WHICH
DOCUMENT IS INCORPORATED

Definitive Proxy Statement for the Annual Meeting of Shareholders to be held May 10, 2005

  PART III

 

 


WELLPOINT, INC.

Indianapolis, Indiana

 

Annual Report to Securities and Exchange Commission

December 31, 2004

 

TAB LE OF CONTENTS

 

         Page

PART I

        

ITEM 1.

  BUSINESS    3

ITEM 2.

  PROPERTIES    25

ITEM 3.

  LEGAL PROCEEDINGS    25

ITEM 4.

  SUBMISSION OF MATTERS TO A VOTE OF SECURITY HOLDERS    29

PART II

        

ITEM 5.

  MARKET FOR REGISTRANT’S COMMON EQUITY, RELATED STOCKHOLDER MATTERS AND ISSUER PURCHASES OF EQUITY SECURITIES    29

ITEM 6.

  SELECTED CONSOLIDATED FINANCIAL DATA    30

ITEM 7.

  MANAGEMENT’S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS    31

ITEM 7A.

  QUANTITATIVE AND QUALITATIVE DISCLOSURES ABOUT MARKET RISK    62

ITEM 8.

  FINANCIAL STATEMENTS AND SUPPLEMENTARY DATA    65

ITEM 9.

  CHANGES IN AND DISAGREEMENTS WITH ACCOUNTANTS ON ACCOUNTING AND FINANCIAL DISCLOSURE    111

ITEM 9A.

  CONTROLS AND PROCEDURES    111

ITEM 9B.

  OTHER INFORMATION    114

PART III

        

ITEM 10.

  DIRECTORS AND EXECUTIVE OFFICERS OF THE REGISTRANT    114

ITEM 11.

  EXECUTIVE COMPENSATION    114

ITEM 12.

  SECURITY OWNERSHIP OF CERTAIN BENEFICIAL OWNERS AND MANAGEMENT AND RELATED STOCKHOLDER MATTERS    114

ITEM 13.

  CERTAIN RELATIONSHIPS AND RELATED TRANSACTIONS    114

ITEM 14.

  PRINCIPAL ACCOUNTANT FEES AND SERVICES    114

PART IV

        

ITEM 15.

  EXHIBITS, FINANCIAL STATEMENT SCHEDULES    115
SIGNATURES        123

INDEX TO EXHIBITS

   125

 

 

1


This Annual Report on Form 10-K, including the Management’s Discussion and Analysis of Financial Condition and Results of Operations, contains forward-looking statements, within the meaning of the Private Securities Litigation Reform Act of 1995, that reflect our views about future events and financial performance. When used in this report, the words “may,” “will,” “should,” “anticipate,” “estimate,” “expect,” “plan,” “believe,” “predict,” “potential,” “intend” and similar expressions are intended to identify forward-looking statements. Forward-looking statements are subject to known and unknown risks and uncertainties that could cause actual results to differ materially from those projected. You are cautioned not to place undue reliance on these forward-looking statements that speak only as of the date hereof. You are also urged to carefully review and consider the various disclosures made by us which attempt to advise interested parties of the factors which affect our business, including Exhibit 99 “Risk Factors” filed as an exhibit hereto and incorporated into this Form 10-K by reference and our reports filed with the Securities and Exchange Commission from time to time.

 

References in this Annual Report on Form 10-K to the term “WellPoint” or the “Company” refer to WellPoint, Inc. and its direct and indirect subsidiaries, as the context requires, after the merger of Anthem, Inc. and WellPoint Health Networks Inc. on November 30, 2004. References to the term “WellPoint Health” or “WHN” refer to WellPoint Health Networks Inc. prior to the merger. References to the terms “we,” “our,” or “us,” refer to WellPoint.

 

2


PART I

 

ITEM 1. BUSINESS.

 

General

 

We are the largest publicly traded commercial health benefits company in terms of membership in the United States, serving more than 27 million medical members as of December 31, 2004. We are an independent licensee of the Blue Cross Blue Shield Association, or BCBSA, an association of independent health benefit plans, and serve our members as the Blue Cross licensee for California and as the Blue Cross and Blue Shield, or BCBS, licensee for twelve other states: Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. We also serve customers throughout various parts of the United States as HealthLink and UniCare. We are licensed to conduct insurance operations in all 50 states and Puerto Rico through our subsidiaries.

 

On November 30, 2004, Anthem, Inc. (“Anthem”) and WellPoint Health Networks Inc. (“WHN”) completed their merger. WHN merged with and into Anthem Holding Corp., a direct and wholly-owned subsidiary of Anthem, with Anthem Holding Corp. as the surviving entity in the merger. In connection with the merger, Anthem amended its articles of incorporation to change its name to WellPoint, Inc. (“WellPoint”).

 

We offer a broad spectrum of network-based managed care plans to the large and small employer, individual, Medicaid and senior markets. Our managed care plans include preferred provider organizations, or PPOs, health maintenance organizations, or HMOs, point-of-service plans, or POS plans, traditional indemnity plans and other hybrid plans, including consumer directed, hospital only and limited benefit products. In addition, we provide a broad array of managed care services to self-funded customers, including claims processing, underwriting, stop loss insurance, actuarial services, provider network access, medical cost management and other administrative services. We also provide an array of specialty and other products and services including pharmacy benefit management, group life and disability insurance, dental, vision, behavioral health benefits, workers compensation and long-term care insurance. For our insured products, we charge a premium and assume all or a majority of the health care risk. Under self-funded and partially insured products, we charge a fee for services, and the employer or plan sponsor reimburses us for all or a majority of the health care costs. Approximately 92% of our 2004 operating revenue was derived from premium income, while approximately 8% was derived from administrative services and other revenues.

 

Our customer base primarily includes large groups with 51 or more employees (47.1% of our medical members at December 31, 2004), and individuals under age 65 and small groups of one to 50 employees (18.8% of our medical members as of December 31, 2004). Other major customer categories include National Accounts, BlueCard Host, Senior (over age 65 individuals and Medicare Supplement or Medicare Advantage policies) and State Sponsored Programs (primarily Medicaid and State Children’s Health Insurance Plans). We market our products through an extensive network of independent agents and brokers (primarily for Individual, Small Group and Senior customers) and through our in-house sales force that are compensated on a commission basis for new sales and retention of existing business (primarily for Large Group customers).

 

The aging of the population and other demographic characteristics and advances in medical technology continue to contribute to rising health care costs. Our managed care plans and products are designed to encourage providers and members to participate in quality, cost-effective health benefit plans by using the full range of our innovative medical management services, quality initiatives and financial incentives. Our leading market shares enable us to realize the long-term benefits of investing in preventive and early detection programs. Our ability to provide cost-effective health benefits products and services is enhanced through a disciplined approach to internal cost containment, prudent management of our risk exposure and successful integration of acquired businesses.

 

3


Our results of operations depend in large part on accurately predicting health care costs and on our ability to manage future health care costs through underwriting criteria, medical management, product design and negotiation of favorable provider contracts.

 

We believe health care is local, and feel that we have the strong local presence required to understand and meet local customer needs. We believe we are well-positioned to deliver what customers want: innovative, choice-based products; distinctive service; simplified administrative transactions; and better access to information for quality care and decision-making.

 

We believe our local presence and national expertise create opportunities for collaborative programs that reward physicians and hospitals for clinical quality and excellence. We feel that our commitment to health improvement and care management provides added value to customers and health care professionals.

 

Like many of our competitors, our vision for the future includes becoming a premier e-business organization by automating interactions with customers, brokers, agents, employees and other stakeholders through web-enabling technology and redesigning internal operations. We are developing our e-business strategy with the goal of becoming widely regarded as an e-business leader in the health benefits industry. The strategy includes not only sales and distribution of health benefits products on the Internet, but also implementation of advanced self-service capabilities benefiting customers, agents, brokers, partners and our associates.

 

We intend to continue to expand through a combination of organic growth and strategic acquisitions in both existing and new markets. Our growth strategy is designed to enable us to take advantage of the additional economies of scale provided by increased overall membership. In addition, we believe geographic diversity reduces our exposure to local or regional regulatory and competitive pressures and provides us with increased opportunities for expansion. While the majority of our growth has been the result of strategic mergers and acquisitions, we have also achieved organic growth in our existing markets by providing excellent service, offering competitively priced products and effectively capturing the brand strength of the Blue Cross and Blue Shield names and marks.

 

WellPoint is an accelerated filer (as defined in Rule 12b-2 of the Securities Exchange Act of 1934, as amended) and is required, pursuant to Item 101 of Regulation S-K, to provide certain information regarding its website and the availability of certain documents filed with or furnished to the Securities and Exchange Commission, or SEC. Our website is www.wellpoint.com. We make available free of charge on or through our Internet website our annual report on Form 10-K, quarterly reports on Form 10-Q, current reports on Form 8-K, and amendments to those reports filed or furnished pursuant to Section 13(a) or 15(d) of the Securities Exchange Act of 1934 as soon as reasonably practicable after we electronically file such material with or furnish it to the SEC.

 

Recent Transactions

 

As discussed above, Anthem and WHN completed their merger on November 30, 2004. Prior to the merger, both Anthem and WHN had individually expanded through organic growth and acquisitions. Listed below are the most recent major transactions that were completed by the pre-merger companies.

 

    On September 24, 2003, WHN completed its acquisition of Cobalt Corporation, the parent company of Blue Cross Blue Shield of Wisconsin.

 

    On July 31, 2002, Anthem completed its purchase of Trigon Healthcare, Inc (“Trigon”). Trigon was the Blue Cross and Blue Shield licensee in Virginia, excluding the Northern Virginia suburbs of Washington, D.C.

 

    On January 31, 2002, WHN completed its acquisition of RightCHOICE Managed Care, Inc., the parent company of Blue Cross and Blue Shield of Missouri (excluding 30 counties in the Kansas City area).

 

4


Industry Overview

 

The health benefits industry has experienced significant change in the last decade. The increasing focus on health care costs by employers, the government and consumers has led to the growth of alternatives to traditional indemnity health insurance. HMO, PPO and hybrid plans, such as POS plans, incorporating features of each, are among the various forms of managed care products that have developed over a number of years. Through these types of products, we attempt to contain the cost of health care by negotiating contracts with hospitals, physicians and other providers to deliver health care at favorable rates. These products usually feature medical management and other quality and cost optimization measures such as pre-admission review and approval for non-emergency hospital services, pre-authorization of outpatient surgical procedures, and network credentialing to determine that network doctors and hospitals have the required certifications and expertise. In addition, providers may share medical cost risk or have other incentives to deliver quality medical services in a cost-effective manner. HMO, PPO and POS members generally are charged periodic, pre-paid premiums, and pay co-payments or deductibles when they receive services. PPO and POS plans provide benefits for out-of-network usage, typically at higher out-of-pocket costs to members. HMO members generally select one of the network’s primary care physicians, who then assume responsibility for coordinating their health care services. Typically, there is no out-of-network benefit for HMO members except in emergencies. PPOs and other open access plans generally provide coverage when members select non-network providers without coordination through a primary care physician, but at a higher out-of-pocket cost. Hybrid plans, such as POS plans, typically involve the selection of primary care physicians similar to HMOs, but allow members to self refer or to choose non-network providers at higher out-of-pocket costs similar to those of PPOs.

 

Recently, economic factors and greater consumer awareness have resulted in the increasing popularity of products that offer larger, more extensive networks, more member choice related to coverage and the ability to self refer within those networks. There is also a growing preference for greater flexibility for customers to assume larger deductibles and co-payments in exchange for lower premiums. We believe we are well positioned in each of our regions to respond to these market preferences. Our PPO products, which contain most or all of the features noted above, have experienced significant growth over the past few years.

 

The BCBSA has also undergone significant change in recent years. Historically, most states had at least one Blue Cross (hospital coverage) and a separate Blue Shield (physician coverage) company. Prior to the mid 1980s there were more than 125 separate Blue Cross or Blue Shield companies. Many of these organizations have merged, reducing the number of independent licensees to 40 as of December 31, 2004.

 

Each of the BCBS companies works cooperatively in a number of ways that create significant market advantages, especially when competing for very large multi-state employer groups. As a result of this cooperation, each BCBS company is able to take advantage of other BCBS licensees’ substantial provider networks and discounts when any member from one state works or travels outside of the state in which the policy is written. This program is referred to as BlueCard®, and is a source of revenue for providing member services in our states for individuals who are customers of other BCBS plans.

 

Competition

 

The managed care industry is highly competitive, both nationally and in our regional markets. Competition continues to be intense due to more aggressive marketing, a proliferation of new products and increased quality awareness and price sensitivity among customers. Significant consolidation within the industry has also added to competition. In addition, with the enactment of the Gramm-Leach-Bliley Act, banks and other financial institutions have the ability to affiliate with insurance companies, which may lead to new competitors in the insurance and health benefits fields.

 

5


Industry participants compete for customers mainly on the following factors:

 

    price;

 

    quality of service;

 

    access to provider networks;

 

    flexibility of benefit designs;

 

    reputation (including NCQA accreditation status);

 

    brand recognition; and

 

    financial stability.

 

Over the last few years, a health plan’s ability to interact with employers, members and other third parties (including health care professionals) via the Internet has become a more important competitive factor. During the last several years, we have made significant technology investments to enhance our electronic interaction with third parties.

 

We believe our exclusive right to market products under the BCBS brand in many of our markets provides us with an advantage over our competition. In addition, our provider networks in our regions enable us to achieve cost-efficiencies and service levels that allow us to offer a broad range of health benefits to our customers on a more cost-effective basis than many of our competitors. We strive to distinguish our products through provider access, excellent service, product value and brand recognition.

 

To build our provider networks, we also compete with other health benefits plans for contracts with hospitals, physicians and other providers. We believe that physicians and other providers primarily consider member volume, reimbursement rates, timeliness of reimbursement and administrative service capabilities along with the reduction of non-value added administrative tasks when deciding whether to contract with a health benefits plan. At the sales and distribution level, we compete for qualified agents and brokers to distribute our products. Strong competition exists among insurance companies and health benefits plans for agents and brokers with demonstrated ability to secure new business and maintain existing accounts. The basis of competition for the services of such agents and brokers are:

 

    commission structure;

 

    support services;

 

    reputation and prior relationships; and

 

    quality of the products.

 

We believe that we have good relationships with our agents and brokers, and that our products, support services and commission structure compare favorably to our competitors in all of our regions.

 

Operating Segments

 

Following the merger with WHN on November 30, 2004, our organizational structure changed. As a result of this change, we established three reportable segments: Health Care, Specialty and Other.

 

Health Care

 

Our Health Care segment is an aggregation of various operating segments, principally differentiated by geographic areas within which we offer similar health benefit products and services. These geographic areas include California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. In addition, UniCare and HealthLink provide services in various other areas of the United States.

 

6


Specialty

 

Our Specialty segment is comprised of businesses providing pharmacy benefit management, group life and disability insurance benefits, dental, workers’ compensation and long-term care insurance. We also provide benefits for vision and behavioral health services.

 

Other

 

Our Other segment is comprised of our Medicare processing business, including AdminaStar Federal and United Government Services; Arcus Enterprises; intersegment revenue and expense eliminations; and corporate expenses not allocated to our Health Care or Specialty segments.

 

For additional information regarding the operating results of our segments, see the Management’s Discussion and Analysis of Financial Condition and Results of Operations and Note 20 to our audited consolidated financial statements for the year ended December 31, 2004 included in this Form 10-K.

 

Products and Services

 

Health Care

 

A general description of our health benefit products and services is provided below:

 

Preferred Provider Organization.    PPO products offer the member an option to select any health care provider, with benefits reimbursed by us at a higher level when care is received from a participating network provider. Coverage is subject to co-payments or deductibles and coinsurance, with member cost sharing usually limited by out-of-pocket maximums.

 

Traditional Indemnity.    Indemnity products offer the member an option to select any health care provider for covered services. Coverage is subject to deductibles and coinsurance, with member cost sharing usually limited by out-of-pocket maximums.

 

Health Maintenance Organization.    HMO products include comprehensive managed care benefits, generally through a participating network of physicians, hospitals and other providers. A member in one of our HMOs must typically select a primary care physician, or PCP, from our network. PCPs generally are family practitioners, internists or pediatricians who provide necessary preventive and primary medical care, and are generally responsible for coordinating other necessary health care services. Preventive care services are emphasized in these plans. We offer HMO plans with varying levels of co-payments, which result in different levels of premium rates.

 

Point-of-Service.    POS products blend the characteristics of HMO and indemnity plans. Members can have comprehensive HMO-style benefits through participating network providers with minimum out-of-pocket expense (co-payments) and also can go directly, without a referral, to any provider they choose, subject to, among other things, certain deductibles and coinsurance. Member cost sharing is limited by out-of-pocket maximums.

 

Management Services.    In addition to fully insured products, we provide administrative services to large group employers that maintain self-funded health plans. These administrative services include underwriting, actuarial services, medical management, claims processing and administrative services for self-funded employers. Self-funded health plans are also able to use our provider networks and to realize savings through our negotiated provider arrangements, while allowing employers the ability to design certain health benefit plans in accordance with their own requirements and objectives. We also write stop loss insurance for self-funded plans.

 

7


Senior Plans.    We offer numerous Medicare supplemental plans, which typically pay the difference between health care costs incurred by a beneficiary and amounts paid by Medicare. We also offer a managed care alternative to the Medicare program in certain geographic areas. We also offer Medicare Advantage plans and Medicare approved drug discount cards in certain geographic regions. Our Medicare Advantage plans provide Medicare beneficiaries with a managed care alternative to traditional Medicare. Our Medicare approved drug discount cards affords Medicare beneficiaries, without prescription drug coverage, access to our drug discounts.

 

BlueCard Plan.    BlueCard host members are generally members who reside in or travel to a state in which a WellPoint subsidiary is the Blue Cross and/or Blue Shield licensee and who are covered under an employer sponsored health plan serviced by a non-WellPoint controlled BCBS licensee, who is the “home” plan. We perform certain administrative functions for BlueCard host members, for which we receive administrative fees from the BlueCard members’ home plans. Other administrative functions, including maintenance of enrollment information and customer service, are performed by the home plan.

 

Medicaid Plans and Other State-Sponsored Programs.    In California, a subsidiary holds contracts with the state to provide managed care programs to MediCal, California’s Medicaid program in a large part of the state. We have also obtained Medicaid contracts to serve members in several other states (and the Commonwealth of Puerto Rico) in which we conduct business.

 

Specialty

 

Pharmacy Products.    We offer pharmacy services and pharmacy benefit management services to our members. Our pharmacy services incorporate features such as drug formularies (where we develop lists of preferred, cost effective drugs), a pharmacy network and maintenance of a prescription drug database and mail order capabilities. Pharmacy benefit management services provided by us include management of drug utilization through outpatient prescription drug formularies, retrospective review and drug education for physicians, pharmacists and members. Two of our subsidiaries are also licensed pharmacies and make prescription dispensing services available through mail order for pharmacy benefit management clients.

 

Life Insurance.    We offer an array of competitive group life insurance benefit products to both large and small group customers in conjunction with our health plans. The life products include term life, accidental death and dismemberment.

 

Disability.    We offer short-term and long-term disability programs, usually in conjunction with our health plans.

 

Behavioral Health.    We offer specialized behavioral health plans and benefit management. These plans cover mental health and substance abuse treatment services on both an inpatient and an outpatient basis. We have implemented employee assistance and behavioral managed care programs for a wide variety of businesses throughout the United States. These programs are offered through our subsidiaries and through third party behavioral health networks.

 

Dental.    Our dental plans include networks in certain states in which we operate. Many of the dental benefits are provided to customers enrolled in our health plans and are offered on both an insured and self-funded basis.

 

Vision Services.    These services are primarily for our customers enrolled in our health plans.

 

Long-Term Care Insurance.    We offer long-term care insurance products to our California members through a subsidiary. The long-term care products include tax-qualified and non-tax qualified versions of a skilled nursing home care plan and comprehensive policies covering skilled, intermediate and custodial long-term care and home health services.

 

Workers Compensation Plan.    We offer workers compensation products to employees principally in the states of Wisconsin, Illinois, Indiana and Iowa.

 

8


Other

 

Medicare Fiscal Intermediary Operations.    Through our AdminaStar Federal and United Government Services subsidiaries, we serve as fiscal intermediaries for the Medicare program, which generally provides coverage for persons who are 65 or older and for persons who are disabled or with end-stage renal disease. Part A of the Medicare program provides coverage for services provided by hospitals, skilled nursing facilities and other health care facilities. Part B of the Medicare program provides coverage for services provided by physicians, physical and occupational therapists and other professional providers. United Government Services serves as the largest Part A fiscal intermediary in the United States. As a fiscal intermediary, we receive reimbursement for certain costs and expenditures.

 

Customer Segmentation

 

Our products are generally developed and marketed with an emphasis on the differing needs of various customer groups. In particular, our product development and marketing efforts take into account the differing characteristics between the various customer groups served by us, including individuals and small employers, large employers, seniors and Medicaid recipients, as well as the unique needs of educational and public entities, federal employee health and benefit programs, national employers and state-run programs servicing low-income, high-risk and under-served markets. Individual business units are responsible for product design, pricing, enrolling, underwriting and servicing customers in specific customer groups. We believe that one of the keys to our success has been the focus on distinct customer groups defined generally by employer size and geographic region, which better enables us to develop benefit plans and services that meet the unique needs of the distinct markets.

 

In each geographic region, we balance the need to customize products with the efficiencies of product standardization. Overall, we seek to establish pricing and product designs to achieve an appropriate level of profitability for each of our customer categories. As of December 31, 2004, our customer types include the following categories:

 

    Large groups include employers with 51 to 4,999 employees eligible to participate as a member in one of our health plans as well as public entities that serve educational and public sector clients. These groups are generally sold through brokers or consultants working with industry specialists from our in-house sales force. Large group cases may be experience rated or sold on a self-insured basis. The customer’s buying decision is typically based upon the size and breadth of our networks, customer service, the quality of our medical management services, the administrative cost included in our quoted price, our financial stability, and our ability to effectively service large complex accounts. Large group also includes members in the Federal Employee Program. As a BCBSA licensee, we participate in a nationwide contract with the Federal government whereby we cover Federal employees and their dependents in our multi-state service area. Under a complex formula, we are reimbursed for our costs plus a fee. We also participate in the overall financial risk for medical claims on a pooled basis with the other participating BCBS companies. Large groups accounted for 47.1% of our members at December 31, 2004.

 

    Individual (under 65) and small groups are defined as members who purchase health insurance services as individuals or through employers with one to 50 eligible employees. While individual policies are generally sold through independent agents and brokers or our in-house sales force, small groups are sold almost exclusively through independent agents and brokers. Small group cases are sold on a fully-insured basis. Underwriting and pricing is typically done on a community rated basis. (See “Regulation—Small Group Reform” below.) Conversely, individual business is usually medically underwritten at the point of initial issuance. Individual and small group customers are generally more sensitive to product pricing and, to a lesser extent, the configuration of the network, and the efficiency of administration. Account turnover is generally higher with individual and small groups as compared to large groups. In several of our markets, there is much less competition for individual business than group contracts. Individuals and small groups accounted for 18.8% of our members at December 31, 2004.

 

9


    National Accounts are defined as multi-state employer groups headquartered in a WellPoint service area with 5,000 or more eligible employees, including 5% or more located in a service area outside of the headquarters state. National Accounts are generally sold through independent brokers or consultants retained by the customer working with our in-house sales force. We have a significant advantage when competing for very large National Accounts due to our ability to access the national provider networks of BCBS companies and take advantage of their provider discounts in their local markets. National Accounts represented 11.6% of our members at December 31, 2004.

 

    BlueCard host customers are defined as enrollees of other BCBS plans, or the “home” plans, who receive health care services in our BCBS licensed markets. BlueCard host membership accounted for 12.5% of our members at December 31, 2004.

 

    Senior customers are defined as members age 65 and over with Medicare Supplement or Medicare Advantage policies. Medicare Supplement policies are sold to Medicare recipients as supplements to the benefits they receive from the Medicare program. Rates are filed with and in some cases approved by state insurance departments. The Medicare Advantage program is the managed care alternative to the federally funded Medicare program. Most of the premium is paid directly by the Federal government on behalf of the participant who may also be charged a small premium. Medicare Supplement and Medicare Advantage products are marketed in the same manner. Senior business accounted for 3.8% of our members at December 31, 2004.

 

    State sponsored program membership are defined as eligible members with state sponsored managed care alternatives for the Medicaid and State Children’s Health Insurance programs that we manage. In 2000, WHN entered into a joint venture with Medical Card Systems, Inc., a Puerto Rico-based group health and life insurer, to pursue contracts under the Health Reform Program in Puerto Rico. As of December 31, 2004, the company’s 50% share of this joint venture served approximately 252,000 members. Total state sponsored program business accounted for 6.2% of our members at December 31, 2004.

 

In addition to reporting our medical membership by customer type, we report by funding arrangement according to the level of risk that we assume in the product contract. Our two principal funding arrangement categories are fully-insured and self-funded. Fully-insured products are products in which we indemnify our policyholders against costs for health benefits. Self-funded products are offered to customers, generally larger employers, who elect to retain some or all of the financial risk associated with their employees’ health care costs. Some employers choose to purchase stop-loss coverage to limit their retained risk. These employers are reported with our self-funded business.

 

10


The following tables set forth our health benefits membership by customer type and funding arrangement, both on a reported basis and a comparable basis assuming the merger of Anthem and WHN had occurred as of December 31, 2003:

 

Reported Basis


     December 31

     2004

   2003

     (In Thousands)

Customer Type

         

Large Group

   13,073    4,708

Individual and Small Group (ISG)

   5,199    1,954

National Accounts

   3,212    1,640

BlueCard

   3,463    2,816
    
  

Total National

   6,675    4,456

Senior

   1,059    599

State Sponsored

   1,722    210
    
  

Total

   27,728    11,927
    
  

Funding Arrangement

         

Self-funded

   13,039    6,412

Fully-insured

   14,689    5,515
    
  

Total

   27,728    11,927
    
  

Comparable Basis 1


     December 31

     2004

   2003

     (In Thousands)

Customer Type

         

Large Group

   13,073    12,740

Individual and Small Group (ISG)

   5,199    4,867

National Accounts

   3,212    2,668

BlueCard

   3,463    2,931
    
  

Total National

   6,675    5,599

Senior

   1,059    1,063

State Sponsored

   1,722    1,781
    
  

Total

   27,728    26,050
    
  

Funding Arrangement

         

Self-funded

   13,039    11,750

Fully-insured

   14,689    14,300
    
  

Total

   27,728    26,050
    
  

 

  1 Comparable basis was calculated by adding historical statistics for the former WHN to historical statistics for the former Anthem and adjusting the combined totals to assure a consistent approach for calculating membership and to eliminate overlapping BlueCard host membership.

 

For additional information regarding the change in membership between years, see the Management’s Discussion and Analysis of Financial Condition and Results of Operations included in this Form 10-K.

 

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Networks and Provider Relations

 

Our relationships with physicians, hospitals and professionals that provide health care services to our members are guided by regional and national standards for network development, reimbursement and contract methodologies.

 

It is generally our philosophy not to delegate full financial responsibility to our physician providers in the form of capitation-based reimbursement. In certain markets we believe capitation can be a useful method to lower costs and reduce underwriting risk and we have some capitation contracts.

 

We attempt to provide market-based hospital reimbursement along industry standards. We also seek to ensure physicians in our network are paid in a timely manner at appropriate rates. We use multi-year contracting strategies, including case or fixed rates, to limit our exposure to medical cost inflation and increase cost predictability. In all regions, we seek to maintain broad provider networks to ensure member choice while implementing programs designed to improve the quality of care received by our members.

 

Depending on the consolidation and integration of physician groups and hospitals, reimbursement strategies vary across markets. Fee for service is our predominant reimbursement methodology for physicians. We generally use a resource-based relative value system (“RBRVS”) fee schedule to determine fee for service reimbursement. However, we also use proprietary fee schedules in certain markets. The RBRVS structure was developed and is maintained by the Centers for Medicare & Medicaid Services, or CMS, and is used by the Medicare program and other major payers. The RBRVS and proprietary systems are independent of submitted fees and therefore is not as vulnerable to inflation. In addition, we are implementing physician incentive contracting which recognizes clinical quality and performance as a basis for reimbursement.

 

Like our physician contracts, our hospital contracts provide for a variety of reimbursement arrangements depending on the network. Our hospital contracts recognize unique hospital attributes (e.g., academic medical centers or community hospitals) and the volume of care performed for our members. Many hospitals are reimbursed on a fixed amount per day for covered services (per diem) or a case rate basis similar to Medicare (Diagnosis Related Groups). Other hospitals are reimbursed on a discount from approved charge basis for covered services. Hospital outpatient services are reimbursed based on fixed case rates, fee schedules or percent of charges. To improve predictability of expected cost, we frequently use a multi-year contracting approach which provides stability in our competitive position versus other health benefit plans in the market, and have been transitioning to case rate payment methodologies. Many of our renewing hospital contracts have reimbursement linked to improved clinical performance, patient safety and medical error reduction.

 

Medical Management Programs

 

Our medical management programs include a broad array of activities that facilitate improvements in the quality of care provided to our members and promote cost effective medical care. These medical management activities and programs are administered and directed by physicians and trained nurses employed by us. One of the goals of our medical management strategies is to assure that the care delivered to our members is supported by appropriate medical and scientific evidence.

 

Precertification.    A traditional medical management program involves assessment of the appropriateness of certain hospitalizations and other medical services. For example, precertification is used to determine whether a set of hospital and medical services is being appropriately applied to the member’s clinical condition, in accordance with criteria for medical necessity as that term is defined in the member’s benefits contract.

 

Concurrent review.    Another traditional medical management strategy we use is concurrent review, which is based on nationally recognized criteria developed for the industry. With concurrent review, the requirements and intensity of services during a patient’s hospital stay are reviewed, often by an onsite skilled nurse

 

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professional in collaboration with the hospital’s medical and nursing staff, in order to coordinate care and determine the most effective transition of care from the hospital setting.

 

Disease management.    We are using more sophisticated care models built around disease management and advanced care management. These programs focus on those members who have chronic and/or complex illness and require the greatest amount of medical services. We provide important information to our physician providers and members to help them optimally manage the care of their specific conditions. For example, certain therapies and interventions for patients with diabetes help prevent some of the serious, long-term medical consequences of diabetes and reduce the risks of kidney, eye and heart disease. Our information systems can provide feedback to our physicians to enable them to improve the quality of care. For other prevalent medical conditions such as heart disease and asthma, our ability to correlate pharmacy data and medical management data allows us to provide important information to our members, physicians and other providers which enables them to more effectively manage these conditions.

 

Advanced care management.    A significant amount of health care expenditures are for services consumed by a small percent of our members who suffer from complex or chronic illnesses. We have developed a series of programs aimed at helping our network physicians better manage and improve the health of these members. Often, these programs provide benefits for home care services and other support to reduce the need for repeated, expensive hospitalizations.

 

Formulary management.    We have developed formularies, which are selections of drugs based on clinical quality and effectiveness. A pharmacy and therapeutics committee uses scientific and clinical evidence to assure that our members have access to the appropriate therapies.

 

Medical policy.    A medical policy group comprised of physician leaders from all of our geographic regions, working in close cooperation with academic medical centers, practicing community physicians, and medical specialty organizations such as the American College of Radiology and national organizations such as the Centers for Disease Control and the American Cancer Society determines our national policy for the application of new technologies.

 

Quality programs.    We are actively engaged with our hospital networks to enable them to improve medical and surgical care and achieve better outcomes for our members. We endorse, encourage and incent hospitals to support national initiatives to improve clinical care, patient outcomes and reduce medication errors and hospital infections. We have been recognized as a national leader in developing hospital quality programs.

 

External review procedures.    In light of public concerns about health plans denying coverage of medical services, we work with outside experts through a process of external review to provide our members scientifically and clinically, evidenced-based medical care. When we receive member concerns, we have formal appeals procedures that ultimately allow coverage disputes related to medical necessity decisions under the benefits contract to be settled by independent expert physicians.

 

Service management.    In HMO and POS networks, primary care physicians serve as the overall coordinators of members’ health care needs by providing an array of preventive health services and overseeing referrals to specialists for appropriate medical care. In PPO networks, patients have access to network physicians without a primary care physician serving as the coordinator of care.

 

Health Care Quality Initiatives

 

Increasingly, the health care industry is able to define quality health care based on preventive health measurements, outcomes of care and optimal care management for chronic disease. A key to our success has been our ability to work with our network physicians and hospitals to improve the quality and outcomes of the health care services provided to our members. Our ability to promote quality medical care has been recognized by the National Committee on Quality Assurance, or NCQA, the largest and most respected national accreditation program for managed care health plans.

 

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A range of quality health care measures, including the Health Plan Employer Data and Information Set, or HEDIS, has been incorporated into the oversight certification by NCQA. HEDIS measures range from preventive services, such as screening mammography and pediatric immunization, to elements of care, including decreasing the complications of diabetes and improving treatment for patients with heart disease. For the HMO and POS plans, NCQA’s highest accreditation is granted only to those plans that demonstrate levels of service and clinical quality that meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement. Plans earning this accreditation level must also achieve HEDIS results that are in the highest range of national or regional performance. For the PPO plans, NCQA’s highest accreditation is granted to those plans that have excellent programs for quality improvement and consumer protection and that meet or exceed NCQA’s standards.

 

In addition, we have initiated a broad array of quality programs, including those built around smoking cessation and transplant management, and increasingly effective hospital and physician quality initiatives centered on women’s health care, diabetes and patient safety.

 

Pricing and Underwriting of Our Products

 

We price our products based on our assessment of underwriting risk, administrative expenses and competitive factors. We continually review our product designs, underwriting and pricing guidelines on a national and regional basis so that our products remain competitive and consistent with our marketing strategies and profitability goals.

 

We have focused our efforts to maintain consistent, competitive and strict underwriting standards. Our individual and group underwriting targets have been based on our proprietary accumulated actuarial data. Subject to applicable legal constraints, we have traditionally employed case specific underwriting procedures for small group products and traditional group underwriting procedures with respect to large group products. Also, we employ credit underwriting procedures with respect to our self-funded products.

 

In most circumstances, our pricing and underwriting decisions follow a prospective rating process. A fixed premium rate is determined at the beginning of the policy period. Unanticipated increases in medical costs may not be able to be recovered in that current policy year. However, prior experience, in the aggregate, is considered in determining premium rates for future periods.

 

For larger groups (over 300 persons) with PPO, POS or traditional benefit designs, we may employ retrospective rating reviews. In retrospective rating, a premium rate is determined at the beginning of the policy period. Once the policy period has ended, the actual experience is reviewed. If the experience is positive (i.e., actual claim costs and other expenses are less than those expected), then a refund may be credited to the policy. If the experience is negative, then the resulting deficit may either be recovered through contractual provisions or the deficit may be considered in setting future premium levels for the group.

 

We have contracts with CMS to provide HMO Medicare Advantage coverage to Medicare beneficiaries who choose health care coverage through one of our HMO programs in certain geographic regions. Under these annual contracts, CMS pays us a set rate based on membership that is adjusted for demographic factors. These rates are subject to annual unilateral revision by CMS. In addition to premiums received from CMS, most of the Medicare products offered by us require a supplemental premium to be paid by the member.

 

See “Regulation—Small Group Reform” below for a discussion of certain regulatory restrictions on our underwriting and pricing.

 

Investments

 

At December 31, 2004, we held investment securities with an estimated fair value of $13.6 billion. Our investment portfolio is subject to credit risk, interest rate risk and market valuation risk. We manage these risks by establishing credit quality limitations as well as dollar limits of individual issuers. Approximately 91% of our

 

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current investments were debt securities, of which approximately 44% included corporate securities. The average credit rating of our corporate fixed maturity portfolio at December 31, 2004 was approximately AA. We evaluate our investment securities on a continuous basis, using both quantitative and qualitative factors, to determine whether a decline in value is other-than-temporary. This review is subjective and requires a high degree of judgment. We believe we have adequately reviewed our investments for impairment and that our investment securities are carried at fair value. For additional information, see the Critical Accounting Policies and Estimates Section of the Management’s Discussion and Analysis of Financial Condition and Results of Operations, Quantitative and Qualitative Disclosures About Market Risk - Investments, and Note 5 to our audited consolidated financial statements for the year ended December 31, 2004 included in this Form 10-K.

 

Liability for Medical Claims Payable

 

We establish and report liabilities or reserves on our balance sheet for medical claims payable by estimating the ultimate cost of incurred claims that have not yet been reported to us by members or providers and reported claims that have not yet been paid. The amounts recorded represent our estimates and the process requires a high degree of judgment. Reserves are established according to Actuarial Standards of Practice and generally accepted actuarial principles and are based on a number of factors. Due to the variability inherent in these assumptions, reserve estimates are sensitive to changes in medical claims payment patterns and changes in medical cost trends. Adjustments to claims liabilities occur each quarter and are sometimes significant as compared to net income recorded in that quarter. As of December 31, 2004, the amount in these liability accounts was $4.2 billion. For additional information, see the Critical Accounting Policies and Estimates section of the Management’s Discussion and Analysis of Financial Condition and Results of Operations and Note 10 to our consolidated audited financial statements included in this Form 10-K.

 

Debt

 

We had approximately $4.3 billion of long-term debt outstanding as of December 31, 2004, an increase of approximately $2.6 billion from year end 2003, primarily a result of funding the WHN merger. Our debt-to-total capital ratio was 18.5% at December 31, 2004, as compared to 21.7% as of December 31, 2003. Our senior debt is rated “BBB+” by Standard & Poor’s, “A-” by Fitch, Inc., “Baa1” by Moody’s Investor Service, Inc. and “a-” by AM Best Company, Inc. We intend to maintain our senior debt investment grade ratings.

 

BCBSA License

 

We have filed for registration of and maintain several service marks, trademarks and trade names at the federal level and in various states in which we operate. We have the exclusive right the use the BCBS names and marks for our health benefits products in California (Blue Cross only), Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin.

 

Each license requires an annual fee to be paid to the BCBSA. The fee is based upon enrollment and premium. BCBSA is a national trade association of Blue Cross and Blue Shield licensees, the primary function of which is to promote and preserve the integrity of the BCBS names and marks, as well as provide certain coordination among the member companies. Each BCBSA licensee is an independent legal organization and is not responsible for obligations of other BCBSA member organizations. We have no right to market products and services using the BCBS names and marks outside of our core states.

 

We believe that the BCBS names and marks are valuable identifiers of our products and services in the marketplace. The license agreements, which have a perpetual term, contain certain requirements and restrictions regarding our operations and our use of the BCBS names and marks. Upon termination of the license agreements, we would cease to have the right to use the BCBS names and marks in one or more of the states that we are authorized to use the marks and the BCBSA could thereafter issue a license to use the BCBS names and marks in

 

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these states to another entity. Events that could cause the termination of a license agreement with the BCBSA include failure to comply with minimum capital requirements, a change of control or violation of the BCBSA ownership limits on our capital stock, impending financial insolvency, the appointment of a trustee or receiver or the commencement of any action against a licensee seeking its dissolution.

 

The license agreements with the BCBSA contain certain requirements and restrictions regarding our operations and our use of the BCBS names and marks, including:

 

    minimum capital and liquidity requirements;

 

    enrollment and customer service performance requirements;

 

    participation in programs that provide portability of membership between plans;

 

    disclosure to the BCBSA relating to enrollment and financial conditions;

 

    disclosures as to the structure of the BCBS system in contracts with third parties and in public statements;

 

    plan governance requirements;

 

    a requirement that at least 80% (or, in the case of Blue Cross of California, substantially all) of a licensee’s annual combined net revenue attributable to health benefit plans within its service area must be sold, marketed, administered or underwritten under the BCBS names and marks;

 

    a requirement that neither a plan nor any of its licensed affiliates may permit an entity other than a plan or a licensed affiliate to obtain control of the plan or the licensed affiliate or to acquire a substantial portion of its assets related to licensable services;

 

    a requirement that we guarantee the contractual and financial obligations of our licensed affiliates; and

 

    a requirement that we indemnify the BCBSA against any claims asserted against us resulting from the contractual and financial obligations of any subsidiary that serves as a fiscal intermediary providing administrative services for Medicare Parts A and B.

 

We believe that we and our licensed affiliates are currently in compliance with these standards. The standards under the license agreements may be modified in certain instances by the BCBSA.

 

Regulation

 

General

 

Our operations are subject to comprehensive and detailed state and federal regulation throughout the United States in the jurisdictions in which we do business. Supervisory agencies, including state health, insurance and corporation departments, have broad authority to:

 

    grant, suspend and revoke licenses to transact business;

 

    regulate many aspects of our products and services;

 

    monitor our solvency and reserve adequacy; and

 

    scrutinize our investment activities on the basis of quality, diversification and other quantitative criteria.

 

To carry out these tasks, these regulators periodically examine our operations and accounts.

 

 

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Regulation of Insurance Company and HMO Business Activity

 

The federal government, as well as the governments of the states in which we conduct our operations, have adopted laws and regulations that govern our business activities in various ways. These laws and regulations, which vary significantly by state, may restrict how we conduct our businesses and may result in additional burdens and costs to us. Areas of governmental regulation include but are not limited to:

 

    licensure;

 

    premium rates;

 

    benefits;

 

    service areas;

 

    market conduct;

 

    utilization review activities;

 

    prompt payment of claims;

 

    universal health care regulation based on the availability to individuals and small groups of a government sponsored health plan administered by a private contractor and funded by increased premium taxes;

 

    assessments for state run immunization programs;

 

    requirements that pharmacy benefit managers pass manufacturers’ rebates to customers;

 

    member rights and responsibilities;

 

    sales and marketing activities;

 

    quality assurance procedures;

 

    plan design and disclosures;

 

    collection, access or use of protected health information;

 

    eligibility requirements;

 

    provider rates of payment;

 

    surcharges on provider payments;

 

    provider contract forms;

 

    provider access standards;

 

    premium taxes and assessments for the uninsured and / or underinsured;

 

    underwriting, marketing and rating restrictions for small group products;

 

    member and provider complaints and appeals;

 

    underwriting and pricing;

 

    financial arrangements;

 

    financial condition (including reserves); and

 

    corporate governance.

 

These laws and regulations are subject to amendments and changing interpretations in each jurisdiction.

 

States generally require health insurers and HMOs to obtain a certificate of authority prior to commencing operations. If we were to establish a health insurance company or an HMO in any state where we do not

 

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presently operate, we generally would have to obtain such a certificate. The time necessary to obtain such a certificate varies from state to state. Each health insurer and HMO must file periodic financial and operating reports with the states in which it does business. In addition, health insurers and HMOs are subject to state examination and periodic license renewal.

 

There has been a recent trend of increased health care regulation at the federal and state levels. Proposed actions and legislation, regulation and initiatives relating to this trend include, among other things, the following:

 

    eliminating or reducing the scope of ERISA pre-emption of state medical and bad faith claims under state law, thereby exposing health benefits companies to expanded liability for punitive and other extra-contractual damages;

 

    requiring an insurer to pay claims during grace periods irrespective of whether a premium is ultimately paid;

 

    extending malpractice and other liability for medical and other decisions from providers to health plans;

 

    imposing liability for negligent denials or delays in coverage;

 

    requiring

 

    coverage of experimental procedures and drugs,

 

    direct access to specialists for patients with chronic conditions,

 

    direct access to specialists (including OB/GYNs) and chiropractors,

 

    direct payment of certain providers (whether or not such providers are participants, e.g., ambulance providers),

 

    expanded consumer disclosures and notices and expanded coverage for emergency services,

 

    liberalized definitions of medical necessity,

 

    liberalized internal and external grievance and appeal procedures (including expedited decision making),

 

    point of service benefits for HMO plans, and

 

    payment of claims within specified time frames or payment of interest on claims that are not paid within those time frames;

 

    prohibiting

 

    so-called “gag” and similar clauses in physician agreements,

 

    incentives based on utilization, and

 

    limitations of arrangements designed to manage medical costs such as capitalized arrangements with providers or provider financial incentives;

 

    regulating and restricting the use of utilization management and review;

 

    restricting our ability to recover overpayments from health care providers;

 

    restricting health plans’ use of different fee schedules for different types of health care providers;

 

    regulating and monitoring the composition of provider networks, such as “any willing provider” and pharmacy laws (which generally provide that providers and pharmacies cannot be denied participation in a managed care plan where the providers and pharmacies are willing to abide by the terms and the conditions of that plan);

 

    imposing payment levels for out-of-network care and restricting the application of lifetime benefit limitations and other limits to mental health benefits with parity;

 

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    exempting physicians from the antitrust laws that prohibit price fixing, group boycotts and other horizontal restraints on competition;

 

    restricting the use of health plan claims information;

 

    restricting the ability to refuse to honor assignment of benefits made so that non-network providers can be paid directly;

 

    regulating procedures that protect the confidentiality of health and financial information;

 

    implementation of a state-run single payer system;

 

    imposing third-party review of denials of benefits (including denials based on a lack of medical necessity);

 

    allowing entry of Multiple Employer Welfare Associations and Association Health Plans into group markets without regulation comparable to regulation of insurers;

 

    limiting an insurer’s withdrawal from and reentry to market segments; and

 

    restricting or eliminating the use of formularies for prescription drugs.

 

The health benefits business also may be adversely impacted by court and regulatory decisions that expand the interpretations of existing statutes and regulations. It is uncertain whether we can recoup, through higher premiums or other measures, the increased costs of mandated benefits or other increased costs caused by potential legislation or regulation.

 

In connection with the WHN merger, certain of our subsidiaries in California and Georgia executed undertakings with the California Department of Managed Health Care, the California Department of Insurance and the Georgia Department of Insurance which contained various commitments, including the commitment to provide $61.5 million of support for health benefit programs in those states. Additional undertakings include the requirement to maintain certain capital levels at those subsidiaries.

 

Small Group Reform

 

All of the principal states in which we do business have enacted statutes that limit the flexibility of us and other health insurers relative to their small group underwriting and rating practices. Commonly referred to as “small group reform” statutes, these laws are generally consistent with model laws originally introduced by the National Association of Insurance Commissioners, or NAIC.

 

The NAIC’s Small Group Health Insurance Availability Model Act is a model law that limits the differentials in rates carriers can charge between new business and health insurance renewal business, and with respect to small groups with similar demographic characteristics (commonly referred to as a “rating law”). It also requires that insurers disclose to customers the basis on which the insurer establishes new business and renewal rates, restricts the applicability of pre-existing condition exclusions and prohibits an insurer from terminating coverage of an employer group because of the adverse claims experience of that group. The model law provides for a voluntary reinsurance mechanism to spread the risk of high risk employees among all small group carriers participating in the reinsurance mechanism. Our representatives actively participated in the committees of the NAIC, which drafted and proposed this model law. NAIC model laws are not applicable to the industry until adopted by individual states, and there is significant variation in the degree to which states adopt and/or alter NAIC model laws. Some, if not all, of these rating and underwriting limitations are present in small group reform statutes currently adopted in all of the principal states in which we do business.

 

Underwriting Limitations.    In the past, insurance companies were free to select and reject risks based on a number of factors, including the medical condition of the person seeking to become insured. Small group health insurers were free to accept some employees and reject other employees for coverage within one employer group. An insurance company was also free to exclude from coverage medical conditions existing within a group which

 

19


the insurance company believed represented an unacceptable risk level. Also, for the most part, insurance companies were free to cancel coverage of a group due to the medical conditions which were present in that group. Additionally, a new employee seeking medical coverage under an existing group plan could be either accepted or rejected for coverage, or could have coverage excluded or delayed for existing medical conditions.

 

The small group health insurance reform laws limit or abolish a number of these commonly utilized practices to address a societal need to extend availability of insurance coverage more broadly to those who were previously not eligible for coverage.

 

Rating Limitations.    Prior to the adoption of state rate reform laws, there was very limited regulation of the rating practices used in the small group health insurance market. There was virtually no regulation of the amount by which one group’s rate could vary from that of a demographically similar group with different claims experience, and there was no statutorily placed limit on the extent and frequency of rate increases that could be applied to any one employer group.

 

All of the principal states in which we do business have enacted rating laws. These laws are designed to reduce the variation in rates charged to insured groups who have favorable and unfavorable claims experience. They also limit the extent and frequency of rate increases. A common rate reform regulation is a pure community rating requirement, pursuant to which all persons in a geographic region would receive the same rate for the same coverage as any other person, without consideration of demographic factors such as age, gender, geographic location, medical risk or occupation. Most existing rating laws also impose a limit on the extent and frequency of a group’s rate increases. At least one state has enacted small group rate regulation that requires the carrier to choose between detailed rate review similar to the review of individual rates or acceptance of minimum loss ratio requirements.

 

Small Group Statutory Reinsurance Mechanisms

 

At this time, our Connecticut and New Hampshire plans are subject to involuntary assessments from small group reinsurance mechanisms within these states. Our plan in New Hampshire is subject to two risk sharing mechanisms. One is an assessment to fund a newly created high risk pool in the individual market. Our New Hampshire plan is also subject to a soon to lapse assessment mechanism to contribute an amount sufficient to cover the expenses and losses of writers of individual products. These mechanisms are designed to provide risk-spreading mechanisms for insurers doing business in jurisdictions that mandate that health insurance be issued on a guarantee issue basis. Guarantee issue requirements increase underwriting risk for insurers by forcing them to accept higher-risk business than they would normally accept. This reinsurance mechanism allows the insurer to cede this high-risk business to the reinsurance facility, thus sharing the underwriting experience with all insurers in the state. Connecticut and New Hampshire statutes subject insurance companies doing business in those jurisdictions to assessments to fund losses from the reinsurance mechanisms. Indiana, Ohio and Nevada statutes provide voluntary reinsurance mechanisms in which the assessment is against only those carriers electing to participate in the reinsurance mechanism. We have elected not to participate in these voluntary reinsurance mechanisms in Indiana and Ohio; however, we do participate in Nevada. Kentucky, Colorado, Maine and Virginia do not have a small group reinsurance mechanism.

 

We also offer Medicare Advantage plans and Medicare approved drug discount cards in certain geographic regions. Our Medicare Advantage plans provide Medicare beneficiaries with a managed care alternative to traditional Medicare. Our Medicare approved drug discount cards affords Medicare beneficiaries, without prescription drug coverage, access to our drug discounts.

 

Medicare Changes

 

In 1997, the federal government passed legislation related to Medicare that changed the method for determining premiums that the government pays to HMOs for Medicare members. In general, the new method has reduced the premiums payable to us compared to the old method, although the level and extent of the

 

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reductions varies by geographic market and depends on other factors. The legislation also requires us to pay a “user fee.” The changes began to be phased in on January 1, 1998 and continued over five years. The federal government also announced in 1999 that it planned to begin to phase in risk adjustments to its premium payments over a five-year period commencing January 1, 2000. While we cannot predict exactly what effect these Medicare reforms will have on our results of operations, we anticipate that the net impact of the risk adjustments will be to reduce the premiums payable to us.

 

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 became law in December 2003 and expanded Medicare, primarily adding a prescription drug benefit for Medicare-eligible retirees starting in 2006.

 

HIPAA and Gramm-Leach-Bliley Act

 

The federal Health Insurance Portability and Accountability Act of 1996, or HIPAA and its regulations, like other small group health insurance laws, impose obligations for issuers of health insurance coverage and health benefit plan sponsors. This law requires guaranteed health care coverage for small employers having 2 to 50 employees and for individuals who meet certain eligibility requirements. It also requires guaranteed renewability of health care coverage for most employers and individuals. The law limits exclusions based on preexisting conditions for individuals covered under group policies to the extent the individuals had prior creditable coverage, and the gap between the prior coverage and the new coverage cannot exceed certain time frames.

 

In addition to the portability component of HIPAA, HIPAA authorized the Secretary of the United States Department of Health and Human Services, known as HHS, to issue standards for administrative simplification, as well as privacy and security of medical records and other individually identifiable patient data. HIPAA requirements apply to health care providers that transmit health information in electronic form in connection with a HIPAA Standard Transaction, as well as to health plans (including insurers and HMOs) and health care clearinghouses (collectively referred to as “Covered Entities”). Privacy and Security Regulations adopted to implement HIPAA also require that Covered Entities obligate their business associates to follow HIPAA standards.

 

Although HIPAA was intended ultimately to reduce administrative expenses and burdens faced within the health care industry, we believe the law has initially brought about significant and, in some cases, costly changes. HHS has released three rules to date mandating the use of new standards with respect to certain health care transactions, including health information. The first rule requires the use of uniform standards for common electronic health care transactions, including health care claims information, plan eligibility, referral certification and authorization, claims status, plan enrollment and disenrollment, payment and remittance advice, plan premium payments and coordination of benefits, and it establishes standards for the use of electronic signatures. The new transaction standards became effective in October 2000. Originally, almost all Covered Entities were required to comply with these standards by October 16, 2002. However, legislation was enacted in December 2001 giving Covered Entities the option of extending their compliance date to October 16, 2003, provided that a filing was made with HHS prior to October 16, 2002. We took advantage of the extension and met our compliance obligations by October 16, 2003. Another rule established a standard for a unique employer identifier to be used in covered electronic transactions. This rule became effective in July 2002. Most Covered Entities were required to comply with this rule by July 30, 2004 and we met our compliance obligation on or before that date. A third rule establishes a national provider identifier to be used in covered electronic transactions. This rule becomes effective in May 2005. Most Covered Entities are required to comply with this rule by May 23, 2007. Additional standard transactions, such as claim attachment standards, are currently under development by HHS.

 

HHS also has developed new standards relating to the privacy of individually identifiable health information or protected health information. In general, these regulations restrict the use and disclosure of medical records and other individually identifiable health information held or disclosed by Covered Entities in any form, whether communicated electronically, on paper or orally, subject only to limited exceptions. In addition, the regulations

 

21


provide patients with some significant new rights to understand and control how their health information is used, and imposed a number of administrative requirements on Covered Entities. These regulations do not preempt more stringent state laws and regulations that may apply to us. Most Covered Entities were required to comply with Privacy Regulations by April 14, 2003 (small health plans were given an additional year to comply). We complied timely with the privacy standards. HHS also issued Security Regulations containing standards that established administrative, physical and technical safeguards to ensure the confidentiality, integrity and availability of electronic protected health information that a covered entity creates, receives, maintains or transmits, protects against any reasonably anticipated threats or hazards to the security or integrity of such information, and protects against any reasonably anticipated uses or disclosures of such information that are not permitted or required under the Privacy Regulation. Most Covered Entities must comply with the Security Regulations by April 20, 2005, and we expect to be in compliance on or before that date.

 

Other federal legislation includes the Gramm-Leach-Bliley Act, which generally placed restrictions on the disclosure of non-public information to non-affiliated third parties, and required financial institutions including insurers, to provide customers with notice regarding how their non-public personal information is used, including an opportunity to “opt out” of certain disclosures. The federal law required state departments of insurance, and certain federal agencies, to adopt implementing regulations, and as such, there has been a great deal of activity at the state and federal level. The Gramm-Leach-Bliley Act also gives banks and other financial institutions the ability to affiliate with insurance companies, which may lead to new competitors in the insurance and health benefits fields.

 

Investment and Retirement Products and Services

 

We are subject to regulation on investment and retirement products and services by various government agencies where we conduct business, including the insurance departments of California, Colorado, Connecticut, Delaware, Georgia, Illinois, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Puerto Rico, Texas, Virginia, and Wisconsin. Among other matters, these agencies may regulate premium rates, trade practices, agent licensing, policy forms, underwriting and claims practices, the maximum interest rates that can be charged on life insurance policy loans, and the minimum rates that must be provided for accumulation of surrender value.

 

ERISA

 

The provision of services to certain employee welfare benefit plans is subject to the Employee Retirement Income Security Act of 1974, as amended, or ERISA, a complex set of laws and regulations subject to interpretation and enforcement by the Internal Revenue Service and the Department of Labor, or DOL. ERISA regulates certain aspects of the relationships between us, the employers who maintain employee welfare benefit plans subject to ERISA and participants in such plans. Some of our administrative services and other activities may also be subject to regulation under ERISA. In addition, some states require licensure or registration of companies providing third party claims administration services for benefit plans. We provide a variety of products and services to employee welfare benefit plans that are covered by ERISA.

 

ERISA prevents ERISA welfare benefit plans from being subject to certain state laws. However, ERISA does not prevent the application of state laws that regulate the business of insurance. The question of whether a state law regulates the business of insurance remains open to interpretation by the courts. In 2002, the United States Supreme Court held that insured health plans provided to employers under ERISA must still comply with state insurance laws which give patients the right to independent external review of medical coverage decisions. Recently, the United States Supreme Court unanimously held that ERISA preempted state law claims against insurers that conflicted with ERISA civil enforcement remedies where insurers use medical judgment to decide a contractual benefit under a welfare benefit plan. This decision settles some open issues regarding ERISA preemption of state laws; however, it is too soon to tell what impact, if any, there will be on our business. The United States Supreme Court has also held that a state’s any willing provider law applies to insured ERISA plans.

 

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In 2001, the DOL promulgated regulations under ERISA setting out standards for claim payment and member appeals along with associated notice and disclosure requirements. These rules became effective for employers with plan years beginning on or after January 1, 2002 for disability plans and July 1, 2002 for health plans.

 

HMO and Insurance Holding Company Laws

 

We are regulated as an insurance holding company and are subject to the insurance holding company acts of the states in which our subsidiaries are domiciled. These acts contain certain reporting requirements as well as restrictions on transactions between an insurer or HMO and its affiliates. These holding company laws and regulations generally require insurance companies and HMOs within an insurance holding company system to register with the insurance department of each state where they are domiciled and to file with those states’ insurance departments certain reports describing capital structure, ownership, financial condition, certain intercompany transactions and general business operations. In addition, various notice and reporting requirements generally apply to transactions between insurance companies and HMOs and their affiliates within an insurance holding company system, depending on the size and nature of the transactions. Some insurance holding company laws and regulations require prior regulatory approval or, in certain circumstances, prior notice of certain material intercompany transfers of assets as well as certain transactions between insurance companies, HMOs, their parent holding companies and affiliates.

 

Additionally, the holding company acts for the states of domicile of our regulated subsidiaries restrict the ability of any person to obtain control of an insurance company or HMO without prior regulatory approval. Under those statutes, without such approval (or an exemption), no person may acquire any voting security of an insurance holding company which controls an insurance company or HMO, or merge with such a holding company, if as a result of such transaction such person would “control” the insurance holding company. “Control” is generally defined as the direct or indirect power to direct or cause the direction of the management and policies of a person and is presumed to exist if a person directly or indirectly owns or controls 10% or more of the voting securities of another person.

 

Guaranty Fund Assessments

 

Under insolvency or guaranty association laws in most states, insurance companies can be assessed for amounts paid by guaranty funds for policyholder losses incurred when an insurance company becomes insolvent. Most state insolvency or guaranty association laws currently provide for assessments based upon the amount of premiums received on insurance underwritten within such state (with a minimum amount payable even if no premium is received). Substantially all of our premiums are currently derived from insurance underwritten in the states of California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Virginia and Wisconsin.

 

Under many of these guaranty association laws, assessments against insurance companies that issue policies of accident or sickness insurance are made retrospectively and are based (up to prescribed percentage of premium limits) upon the ratio of (i) the insurance company’s premiums received in the applicable state over the previous three calendar years on accident and sickness insurance to (ii) the aggregate amount of premiums received by all assessed member insurance companies over such three calendar years on accident and sickness insurance. The guaranty fund assessments made under these acts are administered by the state’s guaranty association, which has its own board of directors selected by member insurers with the approval of the state insurance department. In general, an assessment may be abated or deferred by the guaranty association if, in the opinion of the board of the guaranty association, payment would endanger the ability of the member to fulfill its contractual obligations. The other member insurers, however, may be assessed for the amount of such abatement or deferral. All or a portion of such assessment paid by a member insurance company may be offset against its premium tax liability to the state in question over a multiple year period (generally five to 10 years) following the year in which the assessment was paid. The amount and timing of any future assessments, however, cannot be reasonably estimated and are beyond our control.

 

 

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While the amount of any assessments applicable to life and health guaranty funds cannot be predicted with certainty, we believe that future guaranty association assessments for insurer insolvencies will not have a material adverse effect on our liquidity and capital resources.

 

Risk-Based Capital Requirements

 

The states of domicile of our regulated subsidiaries have statutory risk-based capital, or RBC, requirements for health and other insurance companies based on the RBC Model Act. These RBC requirements are intended to assess the capital adequacy of life and health insurers, taking into account the risk characteristics of an insurer’s investments and products. The RBC Model Act sets forth the formula for calculating the RBC requirements which are designed to take into account asset risks, insurance risks, interest rate risks and other relevant risks with respect to an individual insurance company’s business. In general, under these laws, an insurance company must submit a report of its RBC level to the insurance department or insurance commissioner of its state of domicile for each calendar year.

 

The RBC Model Act provides for four different levels of regulatory attention depending on the ratio of a company’s total adjusted capital (defined as the total of its statutory capital, surplus and asset valuation reserve) to its risk-based capital. The “Company Action Level” is triggered if a company’s total adjusted capital is less than 200 percent but greater than or equal to 150 percent of its risk-based capital. At the “Company Action Level”, a company must submit a comprehensive plan to the regulatory authority which discusses proposed corrective actions to improve its capital position. A company whose total adjusted capital is between 250 percent and 200 percent of its risk-based capital is subject to a trend test. The trend test calculates the greater of any decrease in the margin (i.e., the amount in dollars by which a company’s adjusted capital exceeds its risk-based capital) between the current year and the prior year and between the current year and the average of the past three years, and assumes that the decrease could occur again in the coming year. If a similar decrease in margin in the coming year would result in a risk-based capital ratio of less than 190 percent, then “Company Action Level” regulatory action would be triggered. The “Regulatory Action Level” is triggered if a company’s total adjusted capital is less than 150 percent but greater than or equal to 100 percent of its risk-based capital. At the “Regulatory Action Level”, the regulatory authority will perform a special examination of the company and issue an order specifying corrective actions that must be followed. The “Authorized Control Level” is triggered if a company’s total adjusted capital is less than 100 percent but greater than or equal to 70 percent of its risk-based capital, at which level the regulatory authority may take any action it deems necessary, including placing the company under regulatory control. The “Mandatory Control Level” is triggered if a company’s total adjusted capital is less than 70 percent of its risk-based capital, at which level the regulatory authority is mandated to place the company under its control.

 

The law requires increasing degrees of regulatory oversight and intervention as an insurance company’s RBC declines. The level of regulatory oversight ranges from requiring the insurance company to inform and obtain approval from the domiciling insurance commissioner of a comprehensive financial plan for increasing its RBC, to mandatory regulatory intervention requiring an insurance company to be placed under regulatory control in a rehabilitation or liquidation proceeding. As of December 31, 2004, the RBC levels of our insurance subsidiaries exceeded all RBC thresholds.

 

NAIC IRIS Ratios

 

The NAIC requires review of financial relationships or “tests” called the Insurance Regulatory Information System, or IRIS, that were designed for early identification of companies that may require special attention by insurance regulatory authorities. Insurance companies submit statutory financial data on an annual basis to the NAIC, which in turn analyzes the data using ratios covering eleven categories of data with defined “usual ranges” for each category. An insurance company may fall out of the usual range for one or more ratios because of specific transactions or events that are, in and of themselves, immaterial. Generally, an insurance company will become subject to regulatory scrutiny if its IRIS results fall outside of the usual ranges on four or more of

 

24


the ratios. If a company is outside the ranges on four or more of the ratios, a written explanation is prepared and sent to regulators. None of our insurance subsidiaries is currently subject to regulatory scrutiny based on IRIS ratios.

 

Employees

 

At December 31, 2004, we had approximately 38,000 persons employed on a full-time basis. As of December 31, 2004, a small portion of employees were covered by collective bargaining agreements: approximately 143 employees in the Sacramento, California area with the Office and Professional Employees International Union, Local 29; approximately 169 employees in the greater Detroit, Michigan area with the International Brotherhood of Teamsters, Chauffeurs, Warehousemen and Helpers of America, Local No. 614; and approximately 190 employees in Milwaukee, Wisconsin with the Office and Professional Employees International Union, Local 9. Our employees are an important asset, and we seek to develop them to their full potential. We believe that our relationship with our employees is good.

 

ITEM 2. PROPERTIES.

 

Our principal executive offices are located at 120 Monument Circle, Indianapolis, Indiana. In addition to this property, following the merger with WellPoint Health Networks Inc., we have offices located at 1 WellPoint Way, Thousand Oaks, California that house certain corporate and specialty services. These properties are being leased. In addition, in order to conduct our operations, which have expanded nationally due to our mergers and acquisitions, we lease or own offices in various other locations, including the greater Los Angeles, California area; Denver, Colorado; North Haven, Connecticut; Atlanta and Columbus, Georgia; Manchester, New Hampshire; the greater Chicago, Illinois area; Indianapolis, Indiana; Louisville, Kentucky; South Portland, Maine; Charlestown and Andover, Massachusetts; Dearborn, Michigan; St. Louis, Missouri; Mason/Cincinnati, Ohio; Worthington/Columbus, Ohio; Houston and Plano, Texas; Richmond, Virginia and Milwaukee, Wisconsin. We believe that our properties are adequate and suitable for our business as presently conducted.

 

ITEM 3. LEGAL PROCEEDINGS.

 

Litigation

 

In May 2000, a case titled California Medical Association vs. Blue Cross of California, et. al., was filed in U.S. district court in San Francisco against Blue Cross of California (“BCC”), one of WHN’s subsidiaries. The lawsuit alleges that BCC violated the Racketeer Influenced and Corrupt Organizations Act (“RICO”) (the “CMA Litigation”).

 

In August 2000, WHN was added as a party to Shane v. Humana, et al., a class-action lawsuit brought on behalf of health care providers nationwide alleging RICO violations (the “Shane Litigation”). Effective November 30, 2004, WHN merged with Anthem Holding Corp., a wholly owned subsidiary of the Company.

 

In October 2000, the federal Judicial Panel on Multidistrict Litigation (“MDL”) issued an order consolidating the CMA Litigation, the Shane lawsuit and various other pending managed care class-action lawsuits against other companies before District Court Judge Federico Moreno in the Southern District of Florida for purposes of pretrial proceedings (hereinafter collectively “MDL Cases”). A mediator has been appointed by Judge Moreno and the parties are currently conducting court-ordered mediation. On December 9, 2004, Judge Moreno issued a new scheduling order extending the expert discovery deadline to February 7, 2005 and setting trial for September 6, 2005. On February 11, 2005, the District Court issued an order bifurcating the trial, holding that liability would be determined first, and damages would be tried after liability, if necessary.

 

On September 26, 2002, the Company was added as a defendant to the Shane Litigation.

 

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On May 8, 2003, in a case titled Dr. Allen Knecht, et al., v. Cigna, et al., several chiropractors filed a purported class action in federal district court in Portland, Oregon, naming the Company and WHN, as well as several commercial insurers. This suit alleges that the defendants violated RICO and challenges many of the same practices in regards to chiropractors as other suits in the MDL Cases. This case has been transferred to the MDL docket and is now assigned to Judge Moreno in Miami. This case has been stayed as a tag-along case to the MDL Cases.

 

On May 22, 2003, in a case titled Kenneth Thomas, M.D., et al., v. Blue Cross Blue Shield Association, et al., several medical providers filed suit in federal district court in Miami, Florida against the Blue Cross Blue Shield Association and Blue Cross and Blue Shield plans across the country, including the Company. The suit alleges that the BCBS Association and the BCBS Plans violated RICO and challenges many of the same practices as other suits in the MDL Cases. This case has been assigned to Judge Moreno in Miami. Plaintiffs filed a motion for class certification and the defendants have filed motions to dismiss and motions to compel arbitration. All motions are currently pending before Judge Moreno.

 

On October 17, 2003, in a case titled Jeffrey Solomon, D.C., et al., v. Cigna, et al., several chiropractors and a podiatrist, along with chiropractic and podiatric associations, filed suit in federal district court in Miami, Florida, against ten managed care corporations, including the Company. The suit alleges that the companies violated RICO and challenges many of the same practices as other suits in the MDL Cases. This case has been transferred to the MDL docket and is now assigned to Judge Moreno in Miami. This case has been stayed as a tag-along case to the MDL Cases.

 

On November 4, 2003, in a case titled Jeffrey Solomon, D.C., et al., v. Blue Cross Blue Shield Association, et al., several chiropractors, podiatrists, a psychologist and a physical therapist, along with their professional corporations and trade associations, filed suit in federal district court in Miami, Florida against the Blue Cross Blue Shield Association and Blue Cross and Blue Shield plans across the country, including the Company. The suit alleges that the BCBS Association and the BCBS Plans violated RICO and challenges many of the same practices as other suits in the MDL Cases. This case has been transferred to the MDL docket and is now assigned to Judge Moreno in Miami. Plaintiffs filed a motion for class certification and the defendants have filed motions to dismiss and motions to compel arbitration. All motions are currently pending before Judge Moreno.

 

On February 23, 2004, in a case titled Richard Freiberg, et al., v. United Healthcare, Inc., et al., an acupuncturist and an association promoting acupuncture filed suit in federal court in Miami, Florida against ten managed care corporations, including the Company. The complaint purports to be a class action filed on behalf of all non-physician health care providers, and alleges that the companies involved violated RICO, and challenges many of the same practices as other suits in the MDL Cases. This case has been transferred to the MDL docket and assigned to Judge Moreno. This case has been stayed as a tag-along case to the MDL Cases.

 

On March 11, 1998, Anthem Insurance Companies, Inc., a wholly owned subsidiary of the Company, and its Ohio subsidiary, Community Insurance Company (“CIC”) were named as defendants in a lawsuit, Robert Lee Dardinger, Executor of the Estate of Esther Louise Dardinger v. Anthem Blue Cross and Blue Shield, et al., filed in Newark, Ohio. The plaintiff sought compensatory damages and unspecified punitive damages in connection with claims alleging wrongful death, bad faith and negligence arising out of CIC’s denial of certain claims for medical treatment for Ms. Dardinger. In December 2001, CIC paid $2.5 in compensatory damages for bad faith and $1,350 (actual dollars) for breach of contract, plus accrued interest. In March 2003, Anthem Insurance and CIC paid punitive damages of $30.0 plus interest. Following the March 2003 payment and Satisfaction of Judgment, the Company released pretax reserves of $24.5 to income, which resulted in an after tax benefit of $0.11 per diluted share for the year ended December 31, 2003.

 

On June 27, 2002, in a case titled Academy of Medicine of Cincinnati and Luis Pagani, M.D. v. Aetna Health, Inc., Humana Health Plan of Ohio, Inc., Anthem Blue Cross and Blue Shield, and United Health Care of Ohio, Inc., No. A02004947 filed in the Court of Common Pleas, Hamilton County, Ohio and a case titled Academy of Medicine of Cincinnati and A. Lee Greiner, M.D., Victor Schmelzer, M.D., and Karl S. Ulicny, Jr.,

 

26


M.D. v. Aetna Health, Inc., Humana, Inc., Anthem Blue Cross and Blue Shield, and United Health Care, Inc., No. 02-CI-903 filed in the Boone County, Kentucky Circuit Court, the Academy and certain physicians allege that the defendants acted in combination and collusion with one another to reduce the reimbursement rates paid to physicians in the area and as a direct result of the defendants’ alleged anti-competitive actions, health care in the area has suffered, namely that: there are fewer hospitals; physicians are rapidly leaving the area; medical practices are unable to hire new physicians; and, from the perspective of the public, the availability of health care has been significantly reduced. Each suit seeks class certification, compensatory damages, attorneys’ fees, and injunctive relief to prevent the alleged anti-competitive behavior against the class in the future. The Company is awaiting a decision from the Ohio Supreme Court in connection with procedural motions filed by the defendants. Defendants are seeking a discretionary review with the Kentucky Supreme Court on procedural motions, and filed their petition on February 10, 2005. These suits are in the preliminary stages.

 

On March 26, 2003, in a case titled Irwin v. AdvancePCS, et al. filed in the California Superior Court in Alameda County, California against Advance PCS, WHN and certain of its wholly owned subsidiaries, the plaintiff alleges that the defendants violated California Business and Professions Code Section 17200 by engaging in unfair, fraudulent and unlawful business practices including, among other things, that pharmacy benefit management companies (such as the Company’s subsidiary that does business under the tradename WellPoint Pharmacy Management) engage in unfair practices such as negotiating discounts in prices of drugs from pharmacies and negotiating rebates from drug manufacturers and retaining such discounts and rebates for their own benefit. On July 9, 2004, the court ordered that the case be resolved in arbitration.

 

The Company intends to vigorously defend all these proceedings; however, their ultimate outcomes cannot presently be determined.

 

Prior to the Company’s acquisition of the group benefit operations (“GBO”), John Hancock Mutual Life Insurance Company (“John Hancock”) entered into a number of reinsurance arrangements with respect to personal accident insurance and the occupational accident component of workers’ compensation insurance, a portion of which was originated through a pool managed by Unicover Managers, Inc. Under these arrangements, John Hancock assumed risks as a reinsurer and transferred certain of such risks to other companies. These arrangements have become the subject of disputes, including a number of legal proceedings to which John Hancock is a party. The Company is currently in arbitration with John Hancock regarding these arrangements. The Company believes that it has a number of defenses to avoid any ultimate liability with respect to these matters and believes that such liabilities were not transferred to the Company as part of the GBO acquisition. However, if the Company were to become subject to such liabilities, the Company could suffer losses that might have a material adverse effect on its financial condition, results of operations or cash flows.

 

On October 28, 2003 a case titled Abrams v. WellPoint Health Networks Inc., et al., was filed in the Superior Court of Ventura County, California against WHN and its board of directors alleging that WHN’s directors breached their fiduciary duties to stockholders by approving an Agreement and Plan of Merger with the Company while in possession of non-public information regarding WHN’s financial results for the third quarter of 2003. The lawsuit sought to enjoin WHN from consummating the merger with the Company, unless WHN adopted and implemented a process for obtaining the highest possible price for stockholders, and to rescind any terms of the Agreement and Plan of Merger that have already been implemented. On May 7, 2004, WHN and the plaintiff signed a memorandum of understanding regarding a potential settlement of the action, in which WHN agreed to provide certain additional disclosures on several matters in the joint proxy statement/prospectus sent to WHN’s stockholders beyond those contained in the preliminary proxy statement/prospectus. The settlement would also provide for the payment by WHN of $2.25 million to the plaintiff’s counsel for fees and costs (subject to court approval). No part of the settlement costs will be paid by the WHN directors individually. The settlement would not involve any admissions of breaches of fiduciary duty or other wrongdoing by WHN or any of its directors. The settlement and payment of the plaintiff’s counsel fees would be conditioned upon, among other things, completion of the merger. The settlement agreement was presented to the Superior Court judge assigned to the matter, on January 11, 2005. The judge preliminarily approved the settlement, and scheduled a hearing to consider final approval to take place on July 7, 2005.

 

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Other Contingencies

 

The Company serves as a fiscal intermediary for Medicare Parts A and B. The fiscal intermediaries for these programs receive reimbursement for certain costs and expenditures, which is subject to adjustment upon audit by the Federal Centers for Medicare & Medicaid Services, formerly the Health Care Financing Administration. The laws and regulations governing fiscal intermediaries for the Medicare program are complex, subject to interpretation and can expose an intermediary to penalties for non-compliance. Fiscal intermediaries may be subject to criminal fines, civil penalties or other sanctions as a result of such audits or reviews. While the Company believes it is currently in compliance in all material respects with the regulations governing fiscal intermediaries, there are ongoing reviews by the federal government of the Company’s activities under certain of its Medicare fiscal intermediary contracts.

 

From time to time, the Company and certain of its subsidiaries are parties to various legal proceedings, many of which involve claims for coverage encountered in the ordinary course of business. The Company, like HMOs and health insurers generally, excludes certain health care services from coverage under its HMO, PPO and other plans. The Company is, in its ordinary course of business, subject to the claims of its enrollees arising out of decisions to restrict treatment or reimbursement for certain services. The loss of even one such claim, if it results in a significant punitive damage award, could have a material adverse effect on the Company. In addition, the risk of potential liability under punitive damage theories may increase significantly the difficulty of obtaining reasonable settlements of coverage claims.

 

In addition to the lawsuits described above, the Company is also involved in other pending and threatened litigation of the character incidental to the business transacted, arising out of its insurance and investment operations, and is from time to time involved as a party in various governmental investigations, audits, reviews and administrative proceedings. These investigations, audits and reviews include routine and special investigations by state insurance departments, state attorneys general and the U.S. Attorney General. Such investigations could result in the imposition of civil or criminal fines, penalties and other sanctions. The Company believes that any liability that may result from any one of these actions is unlikely to have a material adverse effect on its consolidated financial position or results of operations.

 

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ITEM 4. SUBMISSION OF MATTERS TO A VOTE OF SECURITY HOLDERS.

 

The Company did not submit any matters to a vote of security holders during the fourth quarter of 2004.

 

PART II

 

ITEM 5. MARKET FOR REGISTRANT’S COMMON EQUITY, RELATED STOCKHOLDER MATTERS AND ISSUER PURCHASES OF EQUITY SECURITIES.

 

Market Prices

 

The Company’s Common Stock, par value $0.01 per share, is listed on the New York Stock Exchange (“NYSE”) under the symbol “WLP”. On March 1, 2005, the closing price on the NYSE was $121.88. As of March 1, 2005, there were 166,845 shareholders of record of the Common Stock. The following table presents high and low sales prices for the Common Stock on the NYSE for the periods indicated.

 

       High

     Low

2004

                 

First Quarter

     $ 92.13      $ 72.50

Second Quarter

       95.60        83.85

Third Quarter

       93.90        77.76

Fourth Quarter

       117.70        72.20

2003

                 

First Quarter

     $ 67.13      $ 53.00

Second Quarter

       82.90        63.80

Third Quarter

       82.00        66.01

Fourth Quarter

       77.96        64.75

 

Dividends

 

No cash dividends have been paid on our common stock. The declaration and payment of future dividends will be at the discretion of our board of directors and must comply with applicable law. Future dividend payments will depend upon our financial condition, results of operations, future liquidity needs, potential acquisitions, regulatory and capital requirements and other factors deemed relevant by our board of directors. In addition, we are a holding company whose primary assets are 100% of the capital stock of Anthem Insurance Companies, Inc., Anthem Southeast, Inc., and Anthem Holding Corp. Our ability to pay dividends to our shareholders, if authorized by our board of directors, is primarily dependent upon the receipt of dividends from these companies and their receipt of dividends from our other regulated insurance subsidiaries.

 

Securities Authorized for Issuance under Equity Compensation Plans

 

The information required by this Item concerning securities authorized for issuance under the Company’s equity compensation plans is set forth in or incorporated by reference into Part III Item 12 of this Form 10-K.

 

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Issuer Purchases of Equity Securities

 

Period


  Total Number
of Shares
Purchased(1)


   Average
Price Paid
per Share


   Total Number
of Shares
Purchased as
Part of
Publicly
Announced
Programs(2)


  

Approximate
Dollar Value
of Shares that
May Yet Be
Purchased
Under the
Programs

(in millions)


October 1, 2004 to October 31, 2004

  —        —      —      $ 700.5

November 1, 2004 to November 30, 2004

  —        —      —        700.5

December 1, 2004 to December 31, 2004

  2,284,101    $ 101.33    —        700.5
   
  

  
  

Total

  2,284,101    $ 101.33    —      $ 700.5
   
  

  
  

 

(1) 2,284,101 shares purchased during the quarter ended December 31, 2004 were due to shares delivered to or withheld by the Company in connection with stock-for-stock option exercises and employee payroll tax withholding upon exercise of stock options and vesting of restricted stock. Stock grants to employees and directors and stock issued for stock option plans and stock purchase plans in the consolidated statements of shareholders’ equity are shown net of these shares purchased.
(2) Represents the number of shares repurchased through our repurchase program authorized by the Board of Directors on January 27, 2003 under which we are authorized to purchase up to $500.0 million prior to February 2005. On October 25, 2004, our Board of Directors authorized an increase of $500.0 million to our repurchase program and extended the expiration date until February 2006. Total available for repurchase following this authorization is $700.5 million.

 

ITEM 6. SELECTED CONSOLIDATED FINANCIAL DATA.

 

The table below provides selected consolidated financial data of WellPoint. The information has been derived from our consolidated financial statements for each of the years in the five year period ended December 31, 2004, which have been audited by Ernst & Young LLP. You should read this selected consolidated financial data in conjunction with the audited consolidated financial statements and notes and “Management’s Discussion and Analysis of Financial Condition and Results of Operations” included in this Form 10-K.

 

    As of and for the Year Ended December 31

 
    20041

    2003

    20021

    2001

    20001

 
    ($ in Millions, Except Per Share Data)  

Income Statement Data

                                       

Total operating revenue2,3

  $ 20,460.9     $ 16,487.1     $ 13,000.4     $ 10,131.3     $ 8,546.4  

Total revenues3

    20,815.1       16,781.4       13,292.2       10,455.7       8,773.9  

Net income4

    960.1       774.3       549.1       342.2       226.0  

Per Share Data4, 5

                                       

Basic income from continuing operations

  $ 6.29     $ 5.60     $ 4.61     $ 3.31     $ 2.19  

Diluted income from continuing operations

    6.10       5.45       4.51       3.30       2.18  

Other Data—(unaudited)

                                       

Benefit expense ratio6

    82.0 %     80.8 %     82.3 %     84.4 %     84.5 %

Selling, general and administrative expense ratio6

    17.0 %     18.8 %     19.3 %     19.6 %     21.3 %

Income before income taxes as a percentage of total revenues

    6.9 %     7.2 %     6.0 %     5.0 %     3.7 %

Net income as a percentage of total revenue

    4.6 %     4.6 %     4.1 %     3.3 %     2.6 %

Medical membership (000s)

    27,728       11,927       11,053       7,883       7,142  

 

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    As of and for the Year Ended December 31

    20041

   2003

   20021

   2001

   20001

    ($ in Millions, Except Per Share Data)

Balance Sheet Data

                                 

Cash and investments3

  $ 15,792.2    $ 7,478.2    $ 6,726.4    $ 4,559.8    $ 3,845.2

Total assets3

    39,738.4      13,414.6      12,416.3      6,325.0      5,688.9

Long-term debt

    4,276.7      1,662.8      1,659.4      818.0      597.5

Total liabilities3

    20,279.4      7,414.7      7,054.0      4,265.0      3,769.1

Total shareholders’ equity7

    19,459.0      5,999.9      5,362.3      2,060.0      1,919.8

1 The net assets and results of operations for Blue Cross Blue Shield of Maine, Trigon Healthcare, Inc. and WellPoint Health Networks Inc. are included from their respective acquisition dates of June 5, 2000, July 31, 2002 and November 30, 2004.
2 Operating revenue is obtained by adding premiums, administrative fees and other revenue.
3 Certain prior year amounts have been reclassified to conform to current year presentation.
4 We adopted FAS 142, Goodwill and Other Intangible Assets, on January 1, 2002. With the adoption of FAS 142, we ceased amortization of goodwill. The intangible assets established for Blue Cross and Blue Shield trademarks are deemed to have indefinite lives, and beginning January 1, 2002, are no longer amortized.

 

Net income and earnings per share on a comparable basis as if FAS 142 had been adopted January 1, 2000, are as follows:

 

    2001

   2000

Net income adjusted for FAS 142

  $ 357.3    $ 238.5

Basic earnings per share adjusted for FAS 142

    3.46      2.32

Diluted earnings per share adjusted for FAS 142

    3.44      2.31

 

5 There were no shares or dilutive securities outstanding prior to November 2, 2001 (date of Anthem Insurance Companies, Inc.’s demutualization and initial public offering). Accordingly, amounts prior to 2002 represent pro forma earnings per share. For comparative pro forma earnings per share presentation, the weighted-average shares outstanding and the effect of dilutive securities for the period from November 2, 2001 to December 31, 2001 was used to calculate pro forma earnings per share for all periods prior to 2002.
6 The benefit expense ratio represents benefit expense as a percentage of premium revenue. The selling, general and administrative expense ratio represents selling, general and administrative expense as a percentage of operating revenue.
7 Represents policyholders’ surplus prior to the demutualization on November 2, 2001.

 

IT EM 7. MANAGEMENT’S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS.

 

Unless the context otherwise requires, references to the terms “we”, “our”, or “us” used throughout this Management’s Discussion and Analysis of Financial Condition and Results of Operations, refer to WellPoint, Inc. (name changed from Anthem, Inc. effective November 30, 2004), an Indiana holding company, and its direct and indirect subsidiaries.

 

The structure of our Management’s Discussion and Analysis of Financial Condition and Results of Operations is as follows:

 

I. Overview

 

II. Significant Transactions

 

III. Membership—December 31, 2004 Compared to December 31, 2003

 

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IV. Cost of Care

 

V. Results of Operations—Year Ended December 31, 2004 Compared to the Year Ended December 31, 2003

 

VI. Membership—December 31, 2003 Compared to December 31, 2002

 

VII. Results of Operations—Year Ended December 31, 2003 Compared to the Year Ended December 31, 2002

 

VIII. Critical Accounting Policies and Estimates

 

IX. Liquidity and Capital Resources

 

X. Safe Harbor Statement Under the Private Securities Litigation Reform Act of 1995

 

I.    Overview

 

We are the nation’s largest publicly traded health benefits company in terms of membership, providing health benefit services to more than 27.7 million members as of December 31, 2004, and we operate as an independent licensee of the Blue Cross Blue Shield Association, or BCBSA. We are the Blue Cross licensee in California and a Blue Cross and Blue Shield licensee in 12 other states: Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the immediate suburbs of Washington, D.C.), and Wisconsin. We also serve customers throughout various parts of the country as HealthLink and UniCare.

 

Our Health Care segment includes strategic business units delineated primarily by geographic areas within which we offer similar products and services, including commercial accounts, senior and Medicaid. We offer a diversified mix of managed care products, including preferred provider organizations or PPOs, health maintenance organizations or HMOs, traditional indemnity benefits and point of service or POS plans. We also offer a variety of hybrid benefit plans, including consumer directed, hospital only and limited benefit products. Additionally, we provide a broad array of managed care services to self-funded customers, including claims processing, underwriting, stop loss insurance, actuarial services, provider network access, medical cost management and other administrative services.

 

Our Specialty segment is comprised of businesses providing pharmacy benefit management, group life and disability insurance benefits, dental, workers’ compensation and long-term care insurance. We also provide vision and behavioral health benefits services.

 

Our Other segment is comprised of our Medicare processing business, including AdminaStar Federal and United Government Services; Arcus Enterprises; intersegment revenue and expense eliminations; and corporate expenses not allocated to our Health Care or Specialty segments.

 

Our operating revenue consists of premiums, administrative fees and other revenue. The premiums come from fully-insured contracts where we indemnify our policyholders against costs for covered health and life benefits. Our administrative fees come from contracts where our customers are self-insured, where the fee is based on either processing of transactions or a percent of network discount savings realized. Additionally, we earn operating revenues from our Medicare processing business and from other health-related businesses including disease management programs. Other revenue is principally generated from member co-payments and deductibles associated with the mail-order sale of drugs by our pharmacy benefit management companies.

 

Our benefit expense includes costs of care for health services consumed by our members, such as outpatient care, inpatient hospital care, professional services (primarily physician care) and pharmacy benefit costs. All four components are affected both by unit costs and utilization rates. Unit costs include the cost of outpatient medical

 

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procedures per visit, inpatient hospital care per admission, physician fees per office visit and prescription drug prices. Utilization rates represent the volume of consumption of health services and typically vary with the age and health status of our members and their social and lifestyle choices, along with clinical protocols and medical practice patterns in each of our markets. A portion of benefit expense recognized in each reporting period consists of actuarial estimates of claims incurred but not yet paid by us. Any changes in these estimates are recorded in the subsequent reporting periods.

 

Our selling expense consists of external broker commission expenses, and generally varies with premium volume. Our general and administrative expense consists of fixed and variable costs. Examples of fixed costs are depreciation, amortization and certain facilities expenses. Other costs are variable or discretionary in nature. Certain variable costs, such as premium taxes, vary directly with premium volume. Other variable costs, such as salaries and benefits, do not vary directly with changes in premium, but are more aligned with changes in membership. The acquisition or loss of a significant block of business would likely impact staffing levels, and thus salary and benefit expense. Discretionary costs include professional and consulting expenses and advertising. Other factors can impact our administrative cost structure, including systems efficiencies, inflation and changes in productivity.

 

Our cost of drugs consists of the amounts we pay to pharmaceutical companies for the drugs we sell via mail order through our pharmacy benefit management companies, or PBM. This amount excludes the cost of drugs related to affiliated health customers recorded in benefit expense. Our cost of drugs can be influenced by the volume of prescriptions at our PBM, as well as cost changes, driven by prices set by pharmaceutical companies and mix of drugs sold.

 

Our results of operations depend in large part on our ability to accurately predict and effectively manage health care costs through effective contracting with providers of care to our members and our medical management programs. Several economic factors related to health care costs, such as regulatory mandates of coverage and direct-to-consumer advertising by providers and pharmaceutical companies, have a direct impact on the volume of care consumed by our members. The potential effect of escalating health care costs as well as any changes in our ability to negotiate competitive rates with our providers may impose further risks to our ability to profitably underwrite our business, and may have a material impact on our results of operations.

 

This management’s discussion and analysis should be read in conjunction with our audited consolidated financial statements for the year ended December 31, 2004, included in this Form 10-K.

 

II.    Significant Transactions

 

On November 30, 2004, Anthem, Inc. and WellPoint Health Networks Inc., or WHN, completed their merger. Under the terms of the merger agreement, the stockholders of WHN (other than subsidiaries of WHN) received consideration of twenty-three dollars and eighty cents ($23.80) in cash and one share of Anthem, Inc. common stock for each WHN share outstanding. In addition, WHN stock options and other awards were converted to WellPoint, Inc. awards in accordance with the merger agreement. The purchase price including cash, fair value of stock and stock awards and estimated transaction costs was approximately $16.0 billion. Anthem, Inc., the surviving corporate parent, was renamed WellPoint, Inc. concurrent with the merger.

 

III.    Membership—December 31, 2004 Compared to December 31, 2003

 

Our medical membership includes six different customer types: Large Group, Individual and Small Group, National Accounts, BlueCard Host, Senior and State Sponsored.

 

   

Large Group consists of those employer customers with 51 to 4,999 employees eligible to participate as a member in one of our health plans. Large Group also includes members in the Federal Employee

 

33


 

Program, or FEP, which provides health insurance coverage to United States government employees and their dependents within our geographic markets through our participation in the national contract between the BCBSA and the U.S. Office of Personnel Management.

 

    Individual and Small Group, or ISG, consists of individual customers under age 65 as well as those employer customers with one to 50 eligible employees.

 

    National Accounts customers are multi-state employer groups primarily headquartered in a WellPoint service area with 5,000 or more eligible employees, with at least 5% of eligible employees located outside of the headquarters state.

 

    BlueCard host members represent enrollees of non-owned Blue Cross and Blue Shield plans who receive health care services in our Blue Cross and Blue Shield licensed markets.

 

    Senior members are Medicare-eligible individual members age 65 and over who have enrolled in Medicare Advantage, a managed care alternative for the Medicare program, or who have purchased Medicare supplement benefit coverage.

 

    State Sponsored membership represents eligible members with state sponsored managed care alternatives in Medicaid and State Children’s Health Insurance programs.

 

BlueCard membership consists of estimated host members using the national BlueCard program. Host members are generally members who reside in or travel to a state in which a WellPoint subsidiary is the Blue Cross and/or Blue Shield licensee and who are covered under an employer sponsored health plan issued by a non-WellPoint controlled Blue Cross Blue Shield licensee (i.e., the “home” plan). We perform certain administrative functions for BlueCard members, for which we receive administrative fees from the BlueCard members’ home plans. Other administrative functions, including maintenance of enrollment information and customer service, are performed by the home plan. Host members are computed using, among other things, the average number of BlueCard claims received per member per month.

 

In addition to reporting our medical membership by customer type, we report by funding arrangement according to the level of risk that we assume in the product contract. Our two funding arrangement categories are fully-insured and self-funded. Fully-insured products are products in which we indemnify our policyholders against costs for health benefits. Self-funded products are offered to customers, generally larger employers, who elect to retain some or all of the financial risk associated with their employees’ health care costs. Some employers choose to purchase stop-loss coverage to limit their retained risk. These employers are reported with our self-funded business.

 

The following table presents our medical membership by customer type, funding arrangement and geographical region as of December 31, 2004 and 2003. Also included below are key metrics from our Specialty segment, including prescription volume for our PBM and membership by product. The membership data presented is unaudited and in certain instances includes estimates of the number of members represented by each contract at the end of the period, rounded to the nearest thousand.

 

     December 31

 

Comparable2

December 31


 
Medical Membership    2004

   20031

  2003

   Change

    %

 
Customer Type    (In Thousands)  

Large Group

   13,073    4,708   12,740    333     3 %

Individual and Small Group (ISG)

   5,199    1,954   4,867    332     7  

National Accounts

   3,212    1,640   2,668    544     20  

BlueCard

   3,463    2,816   2,931    532     18  
    
  
 
  

 

Total National

   6,675    4,456   5,599    1,076     19  

Senior

   1,059    599   1,063    (4 )   —    

State Sponsored

   1,722    210   1,781    (59 )   (3 )
    
  
 
  

 

Total

   27,728    11,927   26,050    1,678     6 %
    
  
 
  

 

 

34


     December 31

 

Comparable2

December 31


 
Medical Membership    2004

   20031

  2003

   Change

    %

 
     (In Thousands)  

Funding Arrangement

                          

Self-Funded

   13,039    6,412   11,750    1,289     11 %

Fully-Insured

   14,689    5,515   14,300    389     3  
    
  
 
  

 

Total

   27,728    11,927   26,050    1,678     6 %
    
  
 
  

 

Regional Membership

                          

Central3

   9,649    5,688   9,090    559     6 %

West

   8,655    939   8,179    476     6  

Southeast

   5,962    2,700   5,456    506     9  

Northeast

   2,546    2,600   2,383    163     7  

Wisconsin4

   916    —     942    (26 )   (3 )
    
  
 
  

 

Total

   27,728    11,927   26,050    1,678     6 %
    
  
 
  

 

Specialty Metrics

                          

PBM Prescription Volume5

   336,541    76,871   299,630    36,911     12 %

Behavioral Health

   11,753    3,171   10,384    1,369     13  

Life and Disability

   5,306    2,230   5,240    66     1  

Dental

   5,048    2,529   5,291    (243 )   (5 )

Vision

   773    423   431    342     79  

 

1 Represents the former Anthem, Inc. only. Historical results have been reclassified to conform to current presentation.
2 “Comparable” statistics were calculated by adding historical statistics for the former WellPoint Health Networks Inc. to historical statistics for the former Anthem, Inc., and adjusting the combined totals to assure a consistent approach for calculating membership and volume statistics and to eliminate overlapping BlueCard host membership.
3 Includes our UniCare and HealthLink membership.
4 Includes 74,742 members of Unity Health Plans Insurance Company which was sold effective January 1, 2005.
5 Represents prescription volume for mail order and retail prescriptions for the full years ended 2004 and 2003, respectively. Prescription volume for 2004 and 2003 is shown on a “comparable” basis.

 

During the twelve months ended December 31, 2004, total comparable medical membership increased approximately 1,678,000, or 6%, primarily in our National Accounts, BlueCard, and ISG businesses. Our National Accounts comparable membership increased 544,000, or 20%, primarily due to recognition of the value of Blue Cross and Blue Shield networks and the discounts we can secure, the breadth of our product offerings, and our distinctive customer service. BlueCard comparable membership increased 532,000, or 18%, representing increased sales by other Blue Cross and Blue Shield licensees to accounts with members who reside in or travel to our licensed areas. ISG comparable membership increased 332,000, or 7%, primarily due to the introduction of new, more affordable product designs and an overall increase in consumer awareness of our wide variety of quality products and services as well as efforts to market products to the uninsured.

 

Self-funded comparable medical membership increased 1,289,000, or 11%, primarily due to increases in our National Accounts and BlueCard businesses. Fully-insured comparable membership increased by 389,000 members, or 3%, primarily in our ISG business.

 

Prescription volume at our PBM increased 36,911,000 prescriptions, or 12%, on a comparable basis in 2004 primarily due to the integration of our Virginia health membership to our internal PBM, as well as increased mail-order utilization and growth within our other existing health lines of business.

 

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Behavioral Health comparable membership increased 1,369,000, or 13%, in 2004 primarily due to HealthLink network growth, the integration of our Maine health customers which were previously serviced by an external vendor, and growth within our other existing health lines of business. Dental comparable membership decreased 243,000, or 5%, in 2004 primarily due to the loss of two specific large accounts. Vision comparable membership increased 342,000, or 79%, due to the integration of internal health members, as well as increased sales.

 

IV.    Cost of Care

 

The following discussion summarizes our aggregate cost of care trends for the full year 2004 for our Large Group and ISG fully-insured businesses only. Cost of care information as discussed below is presented as if pre-merger Anthem, Inc. and WHN were combined for all of 2004 and 2003. Accordingly, cost of care reported previously for pre-merger Anthem, Inc. is not comparable to what is presented below. Our cost of care trends are calculated by comparing the year over year change in average per member per month claim costs for which we are responsible, which excludes member co-payments and deductibles. Our aggregate cost of care trend was just under 10% for 2004.

 

Costs for outpatient services and pharmacy continued to be the primary drivers of overall cost trends. Outpatient services cost trend increases were primarily driven by higher per visit costs as more procedures are being performed during each visit to an outpatient provider, particularly emergency room visits, as well as the impact of price increases included within certain provider contracts. Pharmacy benefit cost trend increases were primarily driven by price increases on existing brand drugs and, to a lesser extent, the introduction of new, higher cost drugs. Price increases on existing brand drugs have been seen particularly in those therapeutic classes of drugs designed to reduce cholesterol and anti-depressants, our two largest categories of drugs based on overall expenses.

 

In response to cost trends, we continue to pursue contracting and plan design changes, promote and implement performance-based contracts that reward clinical outcomes and quality, and expand our disease management and advanced care management programs. In addition, we continually evaluate our drug formulary to ensure the most effective pharmaceutical therapies are available for our members.

 

Late in the third quarter of 2004, the arthritis drug VIOXX® was removed from the market due to concerns about the risk of heart attacks in persons taking this drug for longer than 18 months. We have provided our network physicians with information regarding alternatives to VIOXX and our PBM has implemented a process to ensure appropriate usage of the COX 2 Inhibitor therapeutic class of drugs.

 

Despite the reported shortage of flu vaccine early in the 2004 – 2005 flu season, we have not seen an increase in hospital admissions, physician office visits and use of anti-viral drugs that would indicate a severe flu season in the fourth quarter of 2004. We are beginning to see an increase in these indications in early 2005.

 

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V.    Results of Operations—Year Ended December 31, 2004 Compared to the Year Ended December 31, 2003

 

Our consolidated results of operations for the years ended December 31, 2004 and 2003 are as follows:

 

   

Year Ended1

December 31


    Change

 
    2004

    2003

    $

   %

 
    ($ in Millions, Except Per Share Data)  

Premiums

  $ 18,771.6     $ 15,167.7     $ 3,603.9    24 %

Administrative fees

    1,436.9       1,160.2       276.7    24  

Other revenue

    252.4       159.2       93.2    59  
   


 


 

  

Total operating revenue

    20,460.9       16,487.1       3,973.8    24  

Net investment income

    311.7       278.1       33.6    12  

Net realized gains on investments

    42.5       16.2       26.3    NM2  
   


 


 

  

Total revenue

    20,815.1       16,781.4       4,033.7    24  

Benefit expense

    15,387.8       12,254.5       3,133.3    26  

Selling, general and administrative expense:

                            

Selling expense

    537.2       411.2       126.0    31  

General and administrative expense

    2,940.5       2,686.3       254.2    9  
   


 


 

  

Total selling, general and administrative expense

    3,477.7       3,097.5       380.2    12  

Cost of drugs

    95.0       38.7       56.3    NM2  

Interest expense

    142.3       131.2       11.1    8  

Amortization of other intangible assets

    61.4       47.6       13.8    29  

Merger-related undertakings

    61.5       —         61.5    NM2  

Loss on repurchase of debt

    146.1       —         146.1    NM2  
   


 


 

  

Total expense

    19,371.8       15,569.5       3,802.3    24  
   


 


 

  

Income before income taxes

    1,443.3       1,211.9       231.4    19  

Income taxes

    483.2       437.6       45.6    10  
   


 


 

  

Net income

  $ 960.1     $ 774.3     $ 185.8    24 %
   


 


 

  

Average diluted shares outstanding (in millions)

    157.3       142.0       15.3    11 %

Diluted net income per share

  $ 6.10     $ 5.45     $ 0.65    12 %

Benefit expense ratio3

    82.0 %     80.8 %          120  bp4  

Selling, general and administrative expense ratio5

    17.0 %     18.8 %          (180) bp4  

Income before income taxes as a percentage of total revenue

    6.9 %     7.2 %          (30) bp4  

Net income as a percentage of total revenue

    4.6 %     4.6 %          —    bp4  

Certain of the following definitions are also applicable to all other results of operations tables in this discussion:

 

1 Financial results for 2004 include operations of WHN for the one month period ended December 31, 2004 only. Financial results for 2003 represent the results of the former Anthem, Inc. only and have been reclassified to conform to current presentation.
2 NM = Not meaningful.
3 Benefit expense ratio = Benefit expense ÷ Premiums.
4 bp = basis point; one hundred basis points = 1%.
5 Selling, general and administrative expense ratio = Total selling, general and administrative expense ÷ Total operating revenue.

 

37


Premiums increased $3,603.9 million, or 24%, to $18,771.6 million in 2004, due to the impact of the merger with WHN, and premium rate increases in our Large Group and ISG businesses. Also contributing to premium growth was higher fully-insured membership, primarily in our ISG business. Partially offsetting the growth were shifts by certain customers to self-funding arrangements, resulting in lower revenues. Included in 2003 were premium refunds of $40.4 million issued to policyholders from our Health Care segment, as claims costs in certain lines of business were much lower than expected. Our premium yields, net of buy-downs, for our fully-insured Large Group and ISG businesses were just less than 10% on a rolling 12-month basis as of December 31, 2004, including the business of pre-merger WHN for all periods.

 

Administrative fees increased $276.7 million, or 24%, to $1,436.9 million in 2004, primarily due to increased revenues from self-funded membership, primarily in National businesses, and also due to the impact of the merger with WHN. These increases were partially offset by decreased administrative fees from AdminaStar Federal’s 1-800 Medicare Help Line contract with Centers for Medicare & Medicaid Services, or CMS, which was substantially completed by June 30, 2003.

 

Other revenue is comprised principally of co-payments and deductibles associated with the sale of mail-order drugs by our PBM, which provides its services to members of our Health Care segment and third party clients. Other revenue increased $93.2 million, or 59%, to $252.4 million in 2004, primarily due to additional mail-order prescription volume and increased prices of prescription drugs sold by our PBM, and also due to the impact of the merger with WHN. Increased mail-order prescription volume resulted from both membership increases and additional utilization of our PBM’s mail-order pharmacy option. Effective January 1, 2004, our PBM began to provide pharmacy benefit management services to Virginia customers of our Health Care segment.

 

Net investment income increased $33.6 million, or 12%, to $311.7 million in 2004 primarily due to the merger with WHN. Our investment income also increased in 2004 due to the growth in invested assets from reinvestment of cash generated from operations, partially offset by a decrease in yields from new investments. Yields were lower in 2004 due in part to the impact of a portion of our fixed maturity portfolio being invested in shorter duration investments in anticipation of the WHN merger and the use of cash upon completion of the WHN merger on November 30, 2004. Yields were also lower in part due to an increased allocation of tax exempt securities in 2004, which is expected to enhance after tax income.

 

A summary of our net realized gains on investments for the years ended December 31, 2004 and 2003 is as follows:

 

   

Year Ended

December 31


       
    2004

    2003

    $ Change

 
    ($ in Millions)        

Net realized gains from the sale of fixed maturity securities

  $ 40.6     $ 41.7     $ (1.1 )

Net realized gains from the sale of equity securities

    3.3       0.5       2.8  

Other-than-temporary impairments

    (0.8 )     (24.4 )     23.6  

Other losses

    (0.6 )     (1.6 )     1.0  
   


 


 


Net realized gains on investments

  $ 42.5     $ 16.2     $ 26.3  
   


 


 


 

Other-than-temporary impairments recognized in 2003 were substantially related to our equity security investments, primarily due to the length of time that the securities’ fair value had been less than cost.

 

Benefit expense increased $3,133.3 million, or 26%, to $15,387.8 million in 2004. Benefit expense increased due to the impact of the merger with WHN, and also due to increased cost of care, which was driven primarily by higher costs in outpatient services and drug costs. Included in the 2003 results was a $31.7 million

 

38


net favorable prior year reserve development recorded during the second quarter of 2003 and a $24.5 million favorable adjustment for resolution of a litigation matter in our Health Care segment in the first quarter of 2003. Our benefit expense ratio increased 120 basis points from 80.8% in 2003 to 82.0% in 2004, increasing from lower than anticipated cost of care trends in 2003 and returning to more sustainable levels.

 

Selling, general and administrative expense increased $380.2 million, or 12%, to $3,477.7 million in 2004, primarily due to the impact of the merger with WHN, and also due to increases in volume-sensitive costs such as higher commissions, premium taxes and other expenses associated with growth in our business and higher salary and benefits costs. These increases were partially offset by a decrease in incentive compensation in 2004, and $20.0 million of contributions to our charitable foundation made by our Health Care segment in 2003 which did not recur in 2004. Our selling, general and administrative expense ratio decreased 180 basis points to 17.0% in 2004, primarily due to our growth in operating revenue and the leveraging of costs over these higher revenues.

 

Cost of drugs increased $56.3 million, or 145%, to $95.0 million in 2004, primarily due to higher mail-order prescription volume at our PBM.

 

Interest expense increased $11.1 million, or 8%, to $142.3 million in 2004, primarily due to additional interest expense on the $2.8 billion of debt initially incurred in conjunction with the WHN merger. Debt of $2.8 billion initially incurred in conjunction with the WHN merger was reduced to approximately $1.9 billion at December 31, 2004. Interest expense for this merger-related debt was incurred in December 2004.

 

Amortization of other intangible assets increased $13.8 million, or 29%, to $61.4 million in 2004, primarily due to additional amortization expense on identifiable intangible assets resulting from the WHN merger.

 

Merger-related undertakings were expenses recorded in 2004 related to certain obligations under our agreements with the California Department of Insurance, the California Department of Managed Health Care and the Georgia Department of Insurance. These agreements were related to the merger with WHN.

 

The loss on repurchase of debt incurred in 2004 related to our tender offer for our high coupon surplus notes. Due to the high coupon on this debt and time remaining until stated maturity, the debt was repurchased at a significant premium over book value, which was the driver of the loss.

 

Income tax expense increased $45.6 million, or 10%, to $483.2 million in 2004. Included in 2004 was $44.8 million in tax benefits associated with a change in Indiana laws governing the state’s high-risk health insurance pool recorded during the first quarter of 2004.

 

We use operating gain to evaluate the performance of our reportable segments, as described in FAS 131, Disclosure About Segments of an Enterprise and Related Information. In connection with the WHN merger and related organizational changes, we evaluated FAS 131 criteria and determined our reportable segments to be Health Care, Specialty and Other. This represents a change from pre-merger Anthem, which disclosed each geographic health region as a reportable segment. Operating gain is calculated as total operating revenue less benefit expense, selling, general and administrative expense and cost of drugs. It does not include net investment income, net realized gains (losses) on investments, interest expense, amortization of other intangible assets, merger related undertakings, loss on repurchase of debt or income taxes, as these items are managed in a corporate shared service environment and are not the responsibility of operating segment management. For additional information, see Note 20 to our audited consolidated financial statements included in this Form 10-K. The discussions of segment results for the years ended December 31, 2004 and 2003 presented below are based on operating gain, as described above, and operating margin, which is calculated as operating gain divided by operating revenue. Our definitions of operating gain and operating margin may not be comparable to similarly titled measures reported by other companies.

 

39


Health Care

 

Our Health Care segment’s summarized results of operations for the years ended December 31, 2004 and 2003 are as follows:

 

   

Year Ended

December 31


         
    2004

   2003

   $ Change

   % Change

    ($ in Millions)          

Operating revenue

  $ 19,754.5    $ 16,000.1    $ 3,754.4    23%

Operating gain

  $ 1,505.3    $ 1,174.6    $ 330.7    28%

Operating margin

    7.6%      7.3%           30 bp

 

Operating revenue increased $3,754.4 million, or 23%, to $19,754.5 million in 2004, due to the impact of the merger with WHN, as the results of the acquired health business is included effective November 30, 2004. Operating revenue also increased due to premium rate increases in our Large Group, ISG, and Senior businesses. Also contributing to this growth were membership increases in our ISG and National Accounts businesses.

 

Operating gain increased $330.7 million, or 28%, to $1,505.3 million, due to our merger with WHN, improved underwriting results in our Large Group business, and growth in our National Accounts businesses. Included in the 2003 results was a $31.7 million net favorable prior year reserve development recorded during the second quarter of 2003 and a $24.5 million favorable adjustment for resolution of a litigation matter in the first quarter of 2003. Also included in 2003 were premium refunds of $40.4 million issued to policyholders as claims costs in certain lines of business were much lower than expected. Additionally, our Health Care segment made contributions of $20.0 million to our charitable foundation in 2003 that did not occur in 2004.

 

Specialty

 

Our Specialty segment’s summarized results of operations for the years ended December 31, 2004 and 2003 are as follows:

 

   

Year Ended

December 31


         
    2004

   2003

   $ Change

   % Change

    ($ in Millions)          

Operating revenue

  $ 1,235.2    $ 732.0    $ 503.2    69%

Operating gain

  $ 100.9    $ 69.1    $ 31.8    46%

Operating margin

    8.2%      9.4%           (120) bp

 

Operating revenue increased $503.2 million, or 69%, to $1,235.2 million in 2004, due to the impact of the merger with WHN, as the results of the acquired specialty business is included effective November 30, 2004. Operating revenue also increased due to increased mail-order prescription volume, including more specialty pharmacy prescriptions and increased wholesale drug costs which are passed through to customers of our PBM. Specialty pharmacy prescriptions include higher cost transactions for biopharmaceutical and injectable medications, which are complex in design and administration, and are costly to ship and store. The increased mail-order prescription volume resulted from both membership increases and additional utilization of our PBM’s mail-order pharmacy option. Effective January 1, 2004, our PBM began providing pharmacy benefit management services to our Virginia health members.

 

Operating gain increased $31.8 million, or 46%, to $100.9 million in 2004, due to the impact of the merger with WHN, and increased mail-order prescription volume at our PBM. This improvement was partially offset by operating results in our other specialty businesses.

 

40


Other

 

Our summarized results of operations for our Other segment for the years ended December 31, 2004 and 2003 are as follows:

 

   

Year Ended

December 31


           
    2004

    2003

    $ Change

    % Change

    ($ in Millions)            

Operating revenue from external customers

  $ 212.8     $ 197.8     $ 15.0     8%

Elimination of intersegment revenues

    (741.6 )     (442.8 )     (298.8 )   67%
   


 


 


   

Total operating revenue

    (528.8 )     (245.0 )     (283.8 )   NM

Operating loss

  $ (105.8 )   $ (147.3 )   $ 41.5     (28)%

 

Operating revenue from external customers increased $15.0 million, or 8%, to $212.8 million in 2004, due to the impact of the merger with WHN, as well as an increase in revenues from our Medicare customer service software development contract with CMS. These were partially offset by the loss of our 1-800 Medicare Help Line contract with CMS, which was substantially completed by June 30, 2003. Elimination of intersegment revenues increased $298.8 million, or 67%, reflecting additional sales by our pharmacy benefit management company to our Health Care segment.

 

Operating loss decreased $41.5 million, or 28%, to $(105.8) million in 2004, primarily due to lower incentive compensation expenses.

 

VI.    Membership—December 31, 2003 Compared to December 31, 2002

 

The following table presents our medical membership by customer type, funding arrangement and geographical region as of December 31, 2003 and 2002. Also included below are key metrics from our Specialty segment, including prescription volume for our PBM and membership by product. The membership data presented is unaudited and in certain instances includes estimates of the number of members represented by each contract at the end of the period, rounded to the nearest thousand.

 

     December 31

                 
     20031

     20021

     Change

       %

 
     (In Thousands)  

Medical Membership

      

Customer Type

      

Large Group

   4,708      4,713      (5 )      —   %

Individual and Small Group (ISG)

   1,954      1,737      217        12  

National Accounts

   1,640      1,363      277        20  

BlueCard

   2,816      2,419      397        16  
    
    
    

    

Total National

   4,456      3,782      674        18  

Senior

   599      618      (19 )      (3 )

State Sponsored

   210      203      7        3  
    
    
    

    

Total

   11,927      11,053      874        8 %
    
    
    

    

Funding Arrangement

                             

Self-Funded

   6,412      5,617      795        14 %

Fully-Insured

   5,515      5,436      79        1  
    
    
    

    

Total

   11,927      11,053      874        8 %
    
    
    

    

 

41


     December 31

               
     20031

     20021

     Change

     %

 
     (In Thousands)  

Medical Membership

      

Regional Membership

                           

Central

   5,688      5,234      454      9 %

West

   939      836      103      12  

Southeast

   2,700      2,549      151      6  

Northeast

   2,600      2,434      166      7  

Wisconsin

   —        —        —        —    
    
    
    
    

Total

   11,927      11,053      874      8 %
    
    
    
    

Specialty Metrics

                           

PBM Prescription Volume2

   76,871      61,976      14,895      24 %

Behavioral Health

   3,171      2,676      495      18  

Life and Disability

   2,230      1,971      259      13  

Dental

   2,529      1,488      1,041      70  

Vision

   423      6      417      NM  

                           
  1 Represents the former Anthem, Inc. only. Historical results have been reclassified to conform to current presentation.
  2 Represents prescription volume for mail order and retail prescriptions.

 

During the twelve months ended December 31, 2003, total medical membership increased approximately 874,000, or 8%, primarily in our BlueCard, National Accounts and ISG businesses. BlueCard membership increased 397,000, or 16%, primarily due to increased sales by other Blue Cross and Blue Shield licensees to accounts with members who reside in or travel to our licensed areas. National Accounts membership increased 277,000, or 20%, due to increased sales in our existing markets due to recognition of the value of Blue Cross and Blue Shield networks and the related discounts we can secure, and our competitive advantage resulting from the breadth of our product offerings and distinctive customer service.

 

Also contributing to our medical membership increase were ISG enrollment gains of 217,000, or 12%, primarily due to the introduction of new, more affordable product designs and an overall increase in consumer awareness of our wide variety of quality products and services.

 

Self-funded medical membership increased 795,000, or 14%, primarily due to increases in BlueCard and National Accounts businesses. Fully-insured membership increased by 79,000 members, or 1%, primarily in our ISG businesses, as explained above. In addition, we experienced a change in our mix of business by funding arrangement as certain Large Group and National Accounts customers shifted from fully-insured to self-funded during the year ended December 31, 2003. Due to economic conditions, certain large accounts assumed the health care risk associated with insuring their employees. This shift in funding arrangements did not have a material impact on our financial results for the year ended December 31, 2003.

 

Dental membership increased 1,041,000, or 70%, in 2003 primarily due to the integration of Connecticut health members, and growth from new sales. Vision membership increased 417,000 due to the new product launch, which took place in the fourth quarter of 2002.

 

42


VII.    Results of Operations—Year Ended December 31, 2003 Compared to the Year Ended December 31, 2002

 

Our consolidated results of operations for the years ended December 31, 2003 and 2002 are as follows:

 

   

Year Ended1

December 31


    Change

 
    2003

    2002

    $

    %

 
    ($ in Millions, Except Per Share Data)  

Premiums

  $ 15,167.7     $ 11,937.9     $ 3,229.8     27 %

Administrative fees

    1,160.2       946.8       213.4     23  

Other revenue

    159.2       115.7       43.5     38  
   


 


 


 

Total operating revenue

    16,487.1       13,000.4       3,486.7     27  

Net investment income

    278.1       260.7       17.4     7  

Net realized gains on investments

    16.2       31.1       (14.9 )   (48 )
   


 


 


 

Total revenue

    16,781.4       13,292.2       3,489.2     26  

Benefit expense

    12,254.5       9,821.9       2,432.6     25  

Selling, general and administrative expense:

                             

Selling expense

    411.2       308.0       103.2     34  

General and administrative expense

    2,686.3       2,207.1       479.2     22