By and U.S. Mail. May 2, 2016

Transcription

1 By and U.S. Mail May, 6 Dr. Richard G. Frank Assistant Secretary for Planning and Evaluation United States Department of Health and Human Services Independence Avenue S.W. Washington, D.C. Dear Dr. Frank: When we met with you and your colleagues, you suggested a supplemental analysis of divestiture options for Medicare Advantage (MA) overlaps associated with the Aetna/Humana transaction might be useful. At the meeting, we provided you with an analysis of the overlaps by county for standard individual MA plans, excluding, for example, group plans, such as those offered by employers or unions, and special needs plans. For each county in the United States, the degree of overlap was classified consistent with the structural principles outlined in the antitrust Horizontal Merger Guidelines (Guidelines). Consistent with the Guidelines, counties where the increase in the Herfindahl-Hirschman Index (HHI) is less than or the post-transaction HHI is less than,5 are assumed to present no antitrust risk. Moderately concentrated markets are counties with an increase in HHI of at least and a post-merger HHI between,5 and,5. Highly concentrated markets are counties with an increase in HHI of between and and a post-merger HHI greater than,5. Presumptively anticompetitive counties have an increase in HHI of more than and a post-merger HHI greater than,5. We also assessed the extent to which divestitures could be made to current market participants to restore competition in each county that presents a problematic overlap, i.e., results in a highly concentrated or presumptively anticompetitive market. As you are aware, prior divestitures to remedy government concerns in health plan transactions have not always been successful, particularly when the party purchasing the divested lives is not an existing competitor in the county. For example, an analysis of divestitures required by the Department of Justice in the Humana/Arcadian transaction indicates that two of three acquirers

2 Dr. Richard G. Frank May, 6 Page of of divested lives rapidly lost a substantial portion of the enrollment they acquired. In particular, Cigna purchased divested membership in eight Arkansas counties in the greater Texarkana area, despite having no pre-existing presence in the area. Cigna s business in this area deteriorated quickly, and it exited six of the counties within one year, and the remaining two counties within two years. In light of the difficulties that new entrants face in continuing to serve MA beneficiaries when purchasing divested health plan membership, including building a provider network and building brand loyalty, we analyzed the extent to which existing competitors in a county could be suitable divestiture partners. For each county, we identified a current competitor as a potential divestiture option if: () the competitor currently has more than a 5 percent share in the market to ensure that it has a viable provider network and an established reputation among consumers, and () the divesture of membership to that competitor would not itself result in a transaction that created competitive concerns i.e., the divestiture could not itself result in a presumptively anticompetitive or highly, concentrated markets. Based on these criteria, we identified 68 presumptively anticompetitive counties and 5 highly concentrated counties where there are no viable divestiture partners among current market participants. The attachment (Figure ) presents a map summarizing the location of these counties, with Table providing additional details. More than.8 million MA beneficiaries reside in the 68 presumptively anticompetitive counties where no existing market participants represent viable divestiture options. The supplemental analysis you suggested was to examine whether MA plans in contiguous counties could be considered viable divestiture options. In response, we asked to extend its analysis to consider plans with at least a 5 percent share in a contiguous county in the same state as viable divestiture options. As summarized in the attachment (Figure ) and the Number of Divestiture Options, Adjacent Counties column of Table, 8 of the 68 presumptively anticompetitive counties where we previously found there was not a viable divestiture option, representing 855,9 MA beneficiaries (almost half the counties and beneficiaries) remain without a divestiture partner. In 8 of the 68 remaining counties, representing 464,87 MA members, there is only one potential divestiture partner under these relaxed criteria. In only 6 counties, representing 496,68 MA members, are there two or more divestiture partners. Aetna/Humana: A Closer Look at DOJ s Most Recent Medicare Advantage Merger Enforcement Action Substantial Member Losses, Rapid Market Exits, CMS Sanctions Raise Questions about Divestiture Solutions Viability, The Capital Forum, February, 6, available at Your Department undoubtedly also would want to consider a plan s quality track record in making a determination about the suitability of a divesture option. We rely on the U.S. Census Bureau s County Adjacency File to identify contiguous counties. This file is available at

3 Dr. Richard G. Frank May, 6 Page of A note of caution: A competitor with an existing presence in a neighboring county may appear to be able to expand more easily into an adjacent area by purchasing divested lives than a company with no presence in the area because, for example, it may have some experience with contracting with providers in the general area. In many instances, however, it is just as likely that a company s decision not to expand into contiguous counties is indicative of market factors or strategy decisions that would make the company unlikely to expand to the neighboring county, even if divested lives were offered, and equally unlikely to succeed in serving those MA beneficiaries for a sustained period of time with high-quality services. Consider, for example, Broward County, FL, which the original analysis found to be a presumptively anticompetitive county without a viable divestiture partner. Under our relaxed criteria, several insurers (with market shares of. percent and 4. percent in Broward County, respectively) appear as possible divestiture partners due to their larger presence in neighboring Miami-Dade County. However, the fact that neither (one with a. percent share in Miami- Dade County and the other with a. percent share in Miami-Dade County) have decided to expand into neighboring Broward County, to date, could reflect that the companies do not believe they can be competitive in an area (even though they are close by) where they have no real presence. Please feel free to follow up with us if you would like to discuss this issue further. I can be reached at ()-66-6 or mhatton@aha.org. Sincerely, /s/ Melinda Reid Hatton Senior Vice President & General Counsel cc: William B. Schultz, General Counsel Office of the General Counsel United States Department of Health and Human Services Independence Avenue S.W. Washington, D.C. The Honorable William Baer (Acting) Associate Attorney General United States Department 95 Pennsylvania Avenue, N.W. Washington, DC 5 Attachment

4 ATTACHMENT

5 Figure : Aetna and Humana Medicare Advantage Overlap by County Non-Group MA Plans, Excluding Special Needs Plans, June 5 Counties with apost-merger HHI of at Least,5 and an Increase in HHI of at Least WA _ MT ND Y t~7 MN MI yyy SD W~ NY MI.~~~ CA WSJ AZ NE UT IN OH CO ~ KS IL VA ~' i KY MO OK ~ ~ NM ~ ~ SC TN AR ~ ~ ~ MS AL ~ GA TX ~~ PA FL Counties Without Divestiture Options -Counties With One Divestiture Option Counties With Two or More Divestiture Options

6 r'' t~~ Figure : Aetna and Humana Medicare Advantage Overlap by County -Alternative Divestitures Non-Group MA Plans, Excluding Special Needs Plans, June 5 Counties with apost-merger HHI of at Least,5 and an Increase in HHI of at Least MT ND u ~ MN M~ ~yy SD W~ NY IA MI.~ ~:~ CA NV AZ NE PA UT IN ph a CO KS IL VA ~ '~ i KY MO OK ~ NM ~~ ~,,.. SC AR TN ~ ~ ~ MS AL TX ~ T~ GA y FL N _ Counties Without Divestiture Options j Counties With One Divestiture Option Counties With Two or More Divestiture Options

7 Table : Aetna and Humana Medicare Advantage Overlap by County Non-Group MA Plans, Excluding Special Needs Plans June 5 Presumptively Anticompetitive Counties Without Divestiture Options in the Same County Henry AL % 7.6% 5,576,4 6,95 Houston AL,969 8.% 6.% 4,87,4 5,885 Russell AL,97 8.% 49.8% 4,8 8 4,9 Benton AR,76.7% 6.% 4,69,5 6,9 Carroll AR,78 9.4% 58.7% 4,46,74 6,4 Crawford AR 4,8 6.7% 6.7% 4, ,4 Franklin AR 977.5%.7%,58 669,97 Garland AR 4,76.% 5.%,66,58 5,994 Logan AR,6.% 8.%,5,5,648 Madison AR % 7.% 5,548, 6,669 Montgomery AR 9.% 9.9%,54,88,54 Pulaski AR 8,.6% 9.7%,578 89,46 Scott AR 5 6.% 4.7%,,79 4,8 Sebastian AR 6,45 7.% 6.% 4, ,8 Washington AR 5,57.7% 6.% 4,565,6 6,67 Kent DE,7.5% 5.8% 4,7 59 5, New Castle DE 6,9 58.9%.7% 4,97,65 5,9 Broward FL 5, 7.% 54.7%, , Charlotte FL 4,97 4.%.%,495 89,86 Duval FL,5.8%.%, 889, Lee FL 9,66 5.9% 4.5%,789 9,79 Manatee FL 9,68 4.8% 4.9%,8,6, Palm Beach FL 88,97 4.5% 6.7% 4, , Polk FL 4,8 5.4% 4.%,7 4,64 Sarasota FL, % 6.%,8 94,6 St. Johns FL 8,78 6.9% 48.%, ,4 Barrow GA,949 9.% 9.%,45,684 4,7 Page of 5

8 Bryan GA 87.4%.8%,977,87 5,64 Burke GA 77.4% 67.% 5,9,54 6,67 Camden GA 94 4.% 46.%,97,76 7,6 Chatham GA 9,4 9.8%.%,8,788 4,588 Clarke GA, 9.5% 59.% 4,75, 5,5 Cobb GA 8, %.7%,7 85, Columbia GA,95 7.% 44.4%,9,57 4,646 Evans GA 6.% 4.%,4,65 6,75 Fayette GA,.6% 45.6%,96 969,895 Forsyth GA 5,94 9.5% 6.%,478, 4,6 Gwinnett GA 9,7 5.8% 5.9%,6,85 4, Hall GA 4,75.% 7.%,675,5,87 Harris GA 846.6% 9.6%,595,77,67 Liberty GA % 5.%,75,9,98 Marion GA 4 7.9% 7.% 5,67,58 7,875 McDuffie GA % 56.4% 4,5,4 7,595 McIntosh GA % 4.8%,85,9 4,75 Muscogee GA 4,77.% 4.7%,69 77,4 Newton GA,554 4.% 5.7%,7,7 4,89 Paulding GA,89.6% 8.5%,44,,647 Richmond GA 6,545.7%.%, ,5 Rockdale GA,78 47.%.4%,96,6 5,8 Appanoose IA % 5.9%,66,6 6,866 Benton IA % 4.%,696,8 7,76 Boone IA 6 7.% 6.8%,45,74 6,56 Buchanan IA 56.6% 9.%,97,56 5,959 Butler IA % 6.8%,89,6 5,49 Carroll IA % 4.% 5,49 4,5, Cedar IA % 4.9%,78,5 7, Clinton IA,6 46.% 5.%,58, 5,95 Crawford IA % 4.8% 4,958,9 8,87 Dallas IA,5 6.9%.6% 4,477,57 6,984 Decatur IA 87.8%.% 7,856,44, Page of 5

9 Delaware IA %.4%,646,,87 Dickinson IA % 44.5% 5,6 4,94, Fremont IA 79.7%.% 6,76,9, Grundy IA 8 47.%.7% 4,4, 5,7 Hamilton IA %.%,488,89 5,7 Ida IA 5 58.% 4.7% 5,6 4,864, Iowa IA %.7%,89,5 6,969 Jasper IA % 4.% 4,79,84 6,64 Johnson IA, 5.%.7%,8,96 7, Jones IA % 9.9%,,69 6,9 Keokuk IA 8 57.%.% 4,84,96 5,68 Linn IA 9,577 9.% 49.% 4,79,874 7,95 Lucas IA 64.8% 6.% 5,8 79 5,87 Lyon IA 4.% 59.8% 5,94 4,86, Madison IA % 7.% 5, ,5 Mahaska IA %.8% 5,69,599 6,769 Marion IA % 7.6% 4,5,67 6,69 Marshall IA, 5.4% 7.7 /a 4,,897 5,898 M ills IA 79.8% 4.% 6,67,7 8,879 Monona IA 9 8.%.8% 7,67,9 9,85 Monroe IA 4 5.% 6.9%,88,69 5,57 Muscatine IA %.5%,4,54 5,944 O'Brien IA 6 5.6% 47.4% 5, 4,987, Osceola IA % 4.6% 5, 4,889, Page IA % 5.5% 7,74,66, Plymouth IA 6 9.% 8.8% 8,87,6, Polk IA,78 6.7% 9.8% 4,47,46 6,8 Pottawattamie IA, % 7.7% 4, ,757 Poweshiek IA 9 66.% 5.% 5, 68 5,89 Scott IA 5, % 6.%,4,44 4,745 Sioux IA 7 6.8% 6.% 5,8 4,67, Story IA,7 7.8%.4%,6,7 5,7 Tama IA % 9.% 4,4 97 5,49 Page of 5

10 U nion IA %.% 6,45,55, Warren IA,6 64.% 8.7% 4,76,98 7,58 Washington IA %.% 4,987,77 6,74 Wayne IA % 6.6%,867,6 5,498 Webster IA % 56.7% 5,9 4,9, Winneshiek IA %.9% 4,95,879 7,8 Woodbury IA, % 8% 7,96,456 9,6 Wright IA %. % 5,74 4,86, Adams IL % 5.6% 4,444 4, 8,747 Bond IL 75.%.% 5,98,95 7,888 Boone IL, % 5.% 4,87 4,76 9,568 Brown IL 5 7.% 6.9% 5, 4,669, Bureau IL % 5.4% 4, ,895 Carroll IL %.% 5, ,6 Cass IL 5 4.% 68.9% 5,4,99 7,7 Christian IL 4 9.4% 45.7%,49,775 5,4 Clinton IL 7 7.% 9.9% 5,86 4,94, Coles IL 7 6.% 8.7% 4,65,66 5,4 Cumberland IL % 8.%,55,568 6, De Witt IL % 9.6%,9 57,6 DeKalb IL 5.9% 79.% 6,696,4, Effingham IL 9.8% 9.5% 4, , Fulton IL 789.% 6.6% 4,888,79 8,68 Greene IL % 6.8%,88,46 7,88 Henry IL,9 6.5%.% 5,4 7 5,4 Kendall IL,48.9% 95.% 9,6 74 9,846 Lee IL 7.4% 74.% 5,95, 8,98 Logan IL 6.6% 7.9%,64,58 4,4 Macon IL 94.5%.6%,9,4 4, Macoupin IL 6 6.9% 6.%,65 878,48 Madison IL,47.% 7.9%,896 67,6 Marshall IL 46 7.% 54.% 4,4,874 5,95 Mason IL %.8%,87,9 4,879 Page 4 of 5

11 McLean IL,85 7.9% 44.%, ,69 Menard IL 7.6% 4.%,94,55 4,495 Morgan IL 8. % 5. %,549, 4,68 Moultrie IL %.4%,7,5 4,76 Ogle IL,45 7.% 7.8% 5,68,888 9,568 Peoria IL 6,65 4.% 57.4%,96,64 5,66 Pike IL % 65.9% 4,9,7 7,9 Randolph IL % 4.% 7,56,44, Sangamon IL,68 6.8% 47.8%,8,56 5,9 Shelby IL 77 6.% 7.7% 5,4 4,696, St. Clair IL,4.% 5.4%,4 5,584 Stark IL 78.4% 55.% 4,46,6 5,67 Stephenson IL, %.9% 5,, 8,5 Tazewell IL 4,49 8.8% 5.5%,644, 5,654 Washington IL 7 7.4% 8.6% 5,98 4,8, Winnebago IL,5 5.% 4.% 4,6 4,47 9,8 Woodford IL % 57.%,884,64 5,56 Allen KS 9.6% 64.% 4,85,496 6,49 Atchison KS 4 4.9% 85. % 7,46,54, Bourbon KS % 4.4% 5,88 4,9, Butler KS, % 54.6% 5,4 4,959, Cherokee KS % 4.6% 5, 4,89, Douglas KS,444 4.% 57.7 /a 5, 4,7 9,74 Franklin KS 7.6% 77.4% 6,5,498, Geary KS 7.7% 64.% 4,8,5 6,4 Harvey KS,74 4.5% 56.5% 5,85 4,95, Jackson KS 7.5% 67.5% 5,64 4,86, Jefferson KS 4.% 68.8% 5,7 4,97, Johnson KS, % 4.6% 4,98,94 8,4 Labette KS % 4.% 5,9 4,9, Leavenworth KS,44 8.4% 7.6% 5,9 4,69, Linn KS % 7.6% 6,,998, Miami KS,9 59% 4.8% 5,68 4,8, Page 5 of 5

12 Montgomery KS 47 8.% 9.% 6,98,8, Osage KS % 5.9% 5,7 4,98, Pottawatomie KS % 84.% 7,6,664, Riley KS.% 5.9%,968,68 6,7 Sedgwick KS 4,8 57.7% 4.% 5,4 4,749 9,77 Shawnee KS,4 46.5% 49.6 /o 4,6 4,66 9,8 Wyandotte KS 6,5 7.% 7.% 6,55,945, Ascension LA 6,6.% 75.% 6, ,5 St. Tammany LA 7,7.9% 6.9% 5, ,48 Penobscot ME 4,755.%.6%,99 495,488 York ME 8, 4.% 5.8%,986 79,65 Audrain MO % 4.6% 5,88,58 7,966 Barry MO, /o 4.5%,84,545 7,49 Barton MO % 8. % 5,98,477 7,676 Bates MO % 4.4% 4,65,4 7,69 Benton MO % 44. %,69,94 6,74 Boone MO,645 4.% 4.9%,49, 4,69 Caldwell MO /o 8. % 5, ,4 Callaway MO,7 68.6%.% 5,6,8 8,498 Carroll MO % 4.7%,445,88 5,7 Cass MO 5,6 49.7% 7.% 4,,687 7,77 Cedar MO, 64.8%.9% 5,4 4, 9,57 Christian MO 5,44 6.4% 6.8%,58,95 4,48 Clay MO 6,84.8% 6.% 5,5 4,4 9,4 Clinton MO % 6.%,96,654 5,58 Cole MO,79 7.8% 8.9% 5,75,755 8,48 Cooper MO % 8.% 5,98,46 7,56 Crawford MO,47 9.9% 6.6% 4,97 9 5,65 Dade MO 55 4.% 46.4% 4,76 4, 8,89 Dallas MO, % 5.%,7,6 7,6 Douglas MO,76. % 44. %,6,656 5,96 Franklin MO 7, % 4.% 4, ,8 Gasconade MO % 4.9% 4, ,64 Page 6 of 5

13 Greene MO 8, % 4.%,65,97 4,5 Henry MO % 7.7% 4,67,954 8, Hickory MO % 7.% 4,64 4,4 8,857 Howard MO 74.9%.5% 5,95,5 7,94 Jackson MO,5 9.9% 48.9% 4,9,94 8, Jasper MO,88 9.% 5.6% 4,46 4,9 8,67 Jefferson MO 4,49 8.7% 6.%,66,496 Johnson MO,5 5.7% 56.% 4,498 4,5 8,5 Laclede MO,8 4.8% 45.6% 4,,995 8,5 Lafayette MO,97.% 6.6% 4,569,876 7,445 Lawrence MO,57 8.% 5.%,6,686 5,89 Lincoln MO, 8.5% 8.7% 7,7,457 8,564 Livingston MO %.6%,75, 5,95 Maries MO 9 8.7%.6% 4, , McDonald MO % 6.% 4,876,578 8,455 Miller MO 6 57.%.7% 4,8,68 8, Moniteau MO 8 8.7% 7.% 7,48,84 8, Montgomery MO 9 8.%.% 6,8,955 8,759 Newton MO,9 5.7% 56.6% 4,54 4,8 8,54 Osage MO 78.%.% 6,8,749 8,77 Ozark MO % 65.% 4, ,78 Perry MO 6 9.% 4.5% 4,5 8 5,6 Pettis MO 698.9% 4.%,9,95 5,95 Phelps MO 7.8% 9.%,4,659 6,69 Pike MO % 8.4%,7,76 5,447 Platte MO,6 9.% 66.4% 5,74,848 9, Polk MO,5 5.4% 6.5% 4,5,749 7,8 Pulaski MO % 47.% 4,4 4,45 8,79 Randolph MO 8.9% 8.9%,76,94 5,8 Ray MO 4 9% 7.9% 5,68,5 6,9 Saline MO 486.5% 46.5%,68,98 6,566 St. Charles MO 8,748 5.% 5.4%,5 78,49 St. Clair MO % 5.% 4,4 4,47 8,6 Page 7 of 5

14 St. Louis MO 57,5 6.4% 4.5%,99 8,77 St. Louis City MO,8.% 6.6%,885 9,78 Ste. Genevieve MO 6 8.8% 8.6% 6,7,9 8, Stone MO, /a 5.%,977,5 5,477 Taney MO,664. /o 8.7%,7,4 5,45 Vernon MO 58.% 59.% 4,55,9 5,744 Warren MO, % 7.7% 4, 6 4,9 Washington MO %.%,64,96 5,4 Webster MO,8 44.% 6.%,, 5,54 Wright MO,.% 7.%,45,4 5,569 Alexander NC,78 5.% 7.8%,95,896 4,99 Cabarrus NC 7,7.5% 9.7%, ,8 Caldwell NC 5, 7.% 4.4%,69,8 6,857 Caswell NC, %.7%,648,6,884 Catawba NC 7,989 9.%.%,44,56,699 Durham NC 6,6 45.4%.%,,9 4,95 Gaston NC, % 8.%,4, 4,55 G uilford NC,76.%.6%,854 54,88 I redell NC 7, % 6.%,554 46,8 Mecklenburg NC 7, % 5.8%,648 74,88 Orange NC,65.6%.4%,76 7,46 Person NC,8 9.7% 9.6%,5 76,968 Randolph NC,49.% 9.5%,78 775,5 Rockingham NC 8,78.%. %,889 5,4 Rowan NC 8,55 6.8% 8.9%,44 97,4 U nion NC 5,56 4.4%.7 /a, ,87 Wake NC,48.7% 4.9%,6,6 4, Cass NE % 5.%,89,65 6,54 Dodge NE 7 6.% 7.8 /a 5, 4,7, Douglas NE 5,66 6.8% 4.%, ,7 Lancaster NE,4 7.% 4.4% 5,948,574 9,5 Sarpy NE,68 5.4% 5.%,7,596 6,8 Saunders NE 87 6.% 8.% 4,6,44 8,7 Page 8 of 5

15 Washington NE % 5.8% 5,4,4 7,47 Clark NV 99,4 4.7% 7.5% 4, ,7 Belmont OH,485.% 6.% 4,9 4,7 Brown OH,85 7.% 4%,55,45 4,55 Columbiana OH 5,79.6%.7%, ,75 Delaware OH 5,45.% 6.%,96,97,94 Franklin OH 9, %.%, ,6 Hamilton OH 4,7 9.5%.%,55 6,84 Hancock OH, 5.% 5.7% 4, ,656 Harrison OH 77.6% 9.4%,4,,646 Jefferson OH,777 8.% 6.4%,85,48 4,54 Licking OH 8,6 5.8%.5% 4,8 49 4, Lorain OH 9,454.9%.%,46 647,99 Lucas OH 7, %.%,6 56,7 Mahoning OH 6,55 7.4% 7.9%,58 74,854 Marion OH,84.7% 7.% 5,5,8 7,4 Muskingum OH,.5% 8.4%, ,6 Seneca OH % 7. %,46,47 4,886 Trumbull OH 4,878.5% 6.%, ,9 Union OH,5 5.6%.%, 6,9 Warren OH 9,75 6.7%.4%,98,95 Wood OH,99 9.% 6.6%,98,98 Berks PA 7,45.%.5%,89 558,847 Carbon PA,88 6.%.%,7 4,57 Centre PA 4,676.8% 7.7%,8 65 4,89 Chester PA 4,7 4.% 4.7%,65, 4,65 Clinton PA,496.9% 4.5% 4,7 66 4,88 Crawford PA 4,49.% 4.7%, 94,7 Cumberland PA,4.7%.4%,496 76,59 Dauphin PA,9 9.%.5%,4 7,7 Franklin PA 5,55.7%.9%,8 745,558 Greene PA, %.7%,89 6,75 Huntingdon PA,8.%.%,686 46,9 4 4 Page 9 of 5

16 Lancaster PA 5,98 5.5%.%,9,4 4,4 Lebanon PA 6,4 5.9% 4.5%,594,56 5,54 Luzerne PA, % 4.%, ,8 Lycoming PA 6, 4.% 5.%,89,4 4, Monroe PA 4,8.4%.4%,69 79,97 Perry PA,46.7%.9%,4 669,89 Sullivan PA 4.5% 8.%,4 596,86 Bon Homme SD 8 4.%.% 4,99 5 5,44 Brookings SD 7 7.4% 4.8% 6,8 9 6,547 Clay SD 7.8%.% 4, ,7 Lake SD 49.5%.% 4,5 7 5,86 Lincoln SD,44.5%.9% 5, , McCook SD 9.9%.9% 6,8 55 6,48 Minnehaha SD 6,8.4% 9.% 5, ,68 Moody SD 8.8%.% 5,98 6,5 Union SD %.%,96,89 5,5 Yankton SD 88 6.%.% 4, ,79 Bexar TX 7,68 7.%.4%, ,8 Bowie TX,9 6.% 7.6% 5,468,4 7,78 Collin TX 8,66 7.8%.9%, ,5 Comal TX 5,67 7.% 48.% 4, ,58 Denton TX 5,68 6.%.6% 4,4 7 4,69 Liberty TX,49 5.7%.8%,48 6,674 Midland TX, % 6.8% 4,9,88 6, Montague TX % 58.% 4, ,9 Parker TX,96.5% 7.%,47,67 4,45 Rains TX 6 5.% 67.5% 5,7 74 6, Daggett UT % 5.5% 5,4 4,976, Duchesne UT %.9% 9,44 558, Tooele UT,49 8.% 6.9% 5, ,446 Uintah UT 9 7.% 8.9% 5,895 4,5, Alexandria City VA,4 6.8% 7.5% 4,4 9 5,65 Arlington VA,46.6% 5.% 4, ,5 Page of 5

17 Danville City VA,55.8% 4.7% 4, ,6 Fairfax VA,56 8.7% 6. /a 4, , Fairfax City VA 65. % 8.9% 4, , Gloucester VA % 9.6% 8,467,5, Hampton City VA,497.9% 9.9% 8, ,989 Henry VA,89.9%.8% 5, 5 5,54 Loudoun VA,79 6.6% 9.7%, ,94 Manassas City VA 7 4.5% 4.%,87,94 5,64 Martinsville City VA 89.5% 5.6% 4, ,9 Pittsylvania VA,7. % 7.7% 5, ,49 Prince William VA,859.9% 9.5% 4, ,4 York VA 95 4.% 9.9% 8, ,66 Boone WV 46.9% 66. % 5,59 4,48, Braxton WV % 85.4% 7,5,488, Brooke WV 7 6.5%.9%,787 7,5 Cabell WV,84.5% 74.9% 5,9,7 7,65 Clay WV 5.% 84.8% 7,47,57, Fayette WV /a 7.% 5,7,7 7, Grant WV 68.% 88.7% 7,994,6, Greenbrier WV % 66.% 4,99,4 6,97 Hancock WV % 45.%,676,8 6,94 Harrison WV,66 9.% 74.4% 5,756,6 7,9 Jackson WV 758.4% 54.6% 4,,4 6,57 Kanawha WV 6,65.6% 5.7%,777,96 6,74 Lewis VW 485.8% 7.% 5,78,87 7,589 Lincoln WV 88.5% 78.5% 6,6,77, Logan WV 77.% 86.7% 7,694,6, Marion VW, 5.6% 55.%,7,78 5,45 Marshall WV,6.5% 6.6% 4,67 6 5,8 Mason WV 5 8.8% 6.4% 4,45,67 6,7 Monongalia VW 78.8% 4.9%,6,78 4,845 Morgan WV 5 6.9% 9.% 8,7,77, Nicholas WV, 9.% 78.9% 6,448,45 7,86 Page of 5

18 Ohio M/, % 5. % 4, ,64 Preston WV 57.% 5.8% 4,95,7 7,465 Putnam WV,776.7% 54.8% 4,7,489 6,56 Raleigh WV % 75.6% 6,,69, Randolph WV 95.6% 85.% 7,44,987 9,4 Ritchie WV % 64.5% 5, ,89 Wayne WV,9.6% 89.4% 8,,898, Wetzel WV 5 8.5% 46. /a,,7 4,9 Wirt M/ % 47.8%,77,886 5,64 Wood VW,.% 65.6% 4,84,486 6,9 Wyoming WV 7 6.6% 76.% 6,, 7, Presumptively Anticompetitive Counties With One Divestiture Option in the Same County St. Lucie FL 9,44.9% 5.6%, 99,4 Clayton GA 7,4.% 4.%,4 88, DeKalb GA,6.4% 4.7%,6,4,58 Hancock IL 4 4.9% 66.% 4, ,57 Jersey IL % 5.% 7,6 96 8,555 Butler OH 5,795.8% 4.%,78 66,794 Clark OH 6,44 5.9% 4.4 /a, 459,759 Clermont OH,44 7.6%.7%, ,67 Muskogee OK,7 4.% 67.8% 5, ,59 Adams PA 4, % 5.%,58 447,64 Delaware PA 8, % 4.% 4, 5 4,9 Erie PA 6,68 4.7% 5.%,998 7,69 York PA, %.9%,9 9,6 Medina TX,854.8% 86.7% 7, ,6 ChesterField VA 7,66.8% 74.% 5, ,5 Hanover VA,584.% 8.% 6, ,466 Newport News City VA 4,.5% 8.% 6,65 4 7,5 Berkeley WV,7.7% 85.% 7, ,846 Jefferson WV,4.7% 8.9% 7,6 6 7,67 Taylor WV 4 4.9% 7.% 5,6 7 6,54 Page of 5

19 Upshur M/ 9.% 8.6% 6,8 59 7,8 Presumptively Anticompetitive Counties With Two or More Divestiture Options in the Same County Hillsborough FL 65,5.% 5.%,9 9,68 Martin FL 8,6 5.% 5.%,5 5 4,6 Pinellas FL 77,958.5% 4.%,78 6,986 Cherokee GA 7,6.9% 5.%,8 98,6 Coweta GA,78 4.5% 57.% 4,9 55 4,55 Douglas GA,84.6% 8.4%,69,74,4 Fulton GA 5,9 8.6%.4%,95,4,95 Henry GA 5,785.% 5.8%,4 59,699 Cook IL 8,966.8% 4.7%,5 7,766 4 Boone KY 4,79.% 6.9% 4, ,67 Campbell KY 4,7.9% 55.%,758 5,96 Kenton KY 6,4.4% 59. /a 4, 8 4,9 Grady OK,8.8% 57.% 4,87 4,98 Henrico VA 8,9.7% 7.6% 5,6 9 6,4 Richmond City VA 5,9.9% 7.% 5,5 7 5,67 Highly Concentrated Counties Without Divestiture Options in the Same County Douglas IL %.%, 69,7 Rock Island IL 4,468 6.%.% 4,54 5 4,657 Iberville LA,5.5% 96.6% 9,44 4 9,447 Androscoggin ME 5,45 7.7%.5% 6,7 9 6,6 Cumberland ME,6.8% 4.%,79 9,9 Camden MO,44.% 49.8% 4, , Ashland OH,8.5% 58.4% 4, ,4 Cuyahoga OH 55,4 9.9% 6.%,5 5,44 Fairfield OH 8, 5.9%.8% 5,7 6 5, Lake OH,45.4% 8.4% 5, 74 5,95 Juniata PA,68.% 6.4% 4, ,9 Lackawanna PA 9,564 5.%.% 4,9 5, Lawrence PA 8, %.%,9 45, Page of 5

20 Mercer PA 9,74.8%.%,7,58 Montgomery PA 9,47 6.% 4.8% 4,9 54 5,56 5 Northumberland PA 5,579 7.% 9.7% 5, ,4 Schuylkill PA 6,79 5.% 5.%,46 57,4 Susquehanna PA,59.%.%,49 4,58 Wyoming PA,5 5.% 9.% 4, ,76 Turner SD %.% 6, ,9 Brazoria TX 8,.% 6.%,66 5,767 Rockwall TX,95.8% 8.8% 4, ,95 Davis UT,75 8.%.8%,8 78,6 Salt Lake UT 44,6 7.8% 8.8%, 8,4 Weber UT 9,8 6.% 8.6%,6,466 Highly Concentrated Counties With One Divestiture Option in the Same County White AR,66 5.7% 6.8%,74 9,894 Vermilion IL 4,4 5.6% 5.4%,989 67,55 Caddo LA 6,985.9% 86.6% 7, ,8 East Baton Rouge LA,5.% 79.% 6,5 94 6,77 St. Francois MO,88.5% 55.4% 4, ,6 Burke NC,8.% 6.% 5,7 8 5, Geauga OH,66 9.4% 5.4% 6,68 6,69 4 Bucks PA 9,75.6% 5.4% 5, ,5 6 Snyder PA,4 9.% 7.5% 5,79 4 5,84 U nion PA,99 8.% 6.9% 5,67 5,784 Wayne PA,67. % 8. %,76,856 Chambers TX 967.9% 4.%,85 9,99 Dallas TX 66,8 5.7% 6.8% 4,89 9 4,8 Ellis TX 4,66.%.4% 4,58 8 4,97 4 San Jacinto TX,9.%.% 4, ,7 Mercer WV,464.% 9.5% 8, ,6 Highly Concentrated Counties With Two or More Divestiture Options in the Same County Effingham GA,9.% 78.% 6, ,59 Page 4 of 5

21 Waller TX,9.8% 9.%,4,4 5 Notes: Presumptively Anticompetitive counties have an increase in HHI of more than and apost-merger HHI greater than,5. Highly Concentrated counties have an increase in HHI of between and and apost-merger HHI greater than,5. For number of divestiture options in the same county, a current competitor is considered a potential divestiture option if () the competitor currently has more than a five percent share in the market (to ensure that it has a viable provider network and an established reputation among consumers), and () the divesture of membership to that competitor would not itself result in a transaction that created competitive concerns (i.e., the divestiture could not itself result in a Presumptively Anticompetitive or Highly Concentrated Markets). For number of divestiture options including competitors in adjacent counties, a current competitor is considered a potential divestiture option if () the competitor currently has more than a five percent share in the county (to ensure that it has a viable provider network and an established reputation among consumers) or a five percent market share in an adjacent county in the same state, and () the divesture of membership to that competitor would not itself result in a transaction that created competitive concerns (i.e., the divestiture could not itself result in a Presumptively Anticompetitive or Highly Concentrated Markets). Source: Centers for Medicare &Medicaid Services, June 5 MA Enrollment by Contract/Plan/State/County, available at < cros. gov/research-statistics-data-and-systems/statistics-trends-a nd-reports/m CRAdvPartDE n roldata/month ly- Enrollment-by-Contract-Plan-State-County-Items/Monthly-Enrollment-by-CPSC-5-6. html>. Page 5 of 5