CMS: The Rival That Sets the PriceThin moat

UnitedHealth Group (UNH) — moat facet

In Medicare Advantage UnitedHealth's real rival is the government's rate, which has run below the cost trend for years.

In Medicare Advantage the most important competitor is not another insurer but the rate. The government publishes each year what it will pay plans, and UnitedHealth's 10-K says that "Medicare Advantage rate notices for numerous years have resulted in industry base rates well below the industry forward medical cost trend"1.

How the Medicare rate movedFor yearsbase rates wellbelow cost trend2026 FinalNoticeapproachedexpected trend2027 AdvancedNoticefar below trend2027 FinalNoticemoved towardtrend, still belowQ2 2026M and R revenue42,390MUnitedHealth Group Form 10-K FY2025; Form 10-Q Q2 2026; Q2 2026 release
The price is set elsewhere.

The 2027 cycle followed the pattern. The 10-K described the 2027 Advanced Notice as "far below" the expected cost trend2; the 10-Q says the Final Notice for 2027 moved toward that trend but remains below it3. It also warns that revisions to the risk adjustment model will continue to reduce funding4.

The government also scores the plans. Star ratings affect payments, and for 2026, 78% of UnitedHealthcare's Medicare Advantage members were in plans rated four stars or higher5.

This competitor cannot be out-negotiated, only anticipated. The company's response in 2026 was to reprice and shrink: Medicare & Retirement revenue was $42,390 million in the second quarter, against $42,623 million a year earlier6. Its dependence on the government as a customer is covered on the Major Clients page.

The 10-K is candid about the direction: while the Final Notice for 2026 approached the expected industry forward medical cost trend, the Advanced Notice for 2027 was far below it7. An insurer that has to accept whatever the rate turns out to be can only respond with benefits and membership, which is exactly what UnitedHealthcare did in 2026.

Medicare & Retirement's share of UnitedHealthcare revenue tracks the exposure, about 49% in the second quarter of 20268. If the rate stays below trend and that share stays near half, the price-setter holds the margin down.

Moat trajectory: Narrowing

2027 final notice still below cost trend; risk model revisions continue.

The number that tests this moat
Moat Explorer calc
Medicare & Retirement share of UnitedHealthcare revenue, latest quarter
About 49% (Q2 2026: $42,390M of $86,017M)

Exposure to the government-set rate; a higher share with rates below trend compresses margins.

How it's calculated: Medicare & Retirement revenue divided by UnitedHealthcare revenue, Q2 2026 results release.
Source: Moat Explorer calculation from UnitedHealth Group filings ↗
References
  1. ReportedThe government publishes each year what it will pay plans, and UnitedHealth's 10-K says that "Medicare Advantage rate notices for numerous years have resulted in industry base rates well below the industry forward medical cost trend".
    UnitedHealth Group Form 10-K for fiscal 2025 - Item 1A risk factors, competition, rate notices, reserve sensitivities and legal matters. — FY2025 · publ. 2 March 2026 · source ↗
  2. ReportedThe 10-K described the 2027 Advanced Notice as "far below" the expected cost trend; the 10-Q says the Final Notice for 2027 moved toward that trend but remains below it.
    UnitedHealth Group Form 10-K for fiscal 2025 - Item 1A risk factors, competition, rate notices, reserve sensitivities and legal matters. — FY2025 · publ. 2 March 2026 · source ↗
  3. ReportedThe 10-K described the 2027 Advanced Notice as "far below" the expected cost trend; the 10-Q says the Final Notice for 2027 moved toward that trend but remains below it.
    UnitedHealth Group Form 10-Q for the quarter ended 30 June 2026 - segment note on the 2026 basis, share repurchases, legal matters and the IRS notices. — Q2 2026 · publ. 10 August 2026 · source ↗
  4. ReportedIt also warns that revisions to the risk adjustment model will continue to reduce funding.
    UnitedHealth Group Form 10-Q for the quarter ended 30 June 2026 - segment note on the 2026 basis, share repurchases, legal matters and the IRS notices. — Q2 2026 · publ. 10 August 2026 · source ↗
  5. ReportedStar ratings affect payments, and for 2026, 78% of UnitedHealthcare's Medicare Advantage members were in plans rated four stars or higher.
    Fierce Healthcare, '2026 MA Star Ratings: Aetna, Humana see scores decline; UnitedHealthcare improves'. — October 2025 · publ. 10 October 2025 · source ↗
  6. ReportedThe company's response in 2026 was to reprice and shrink: Medicare & Retirement revenue was $42,390 million in the second quarter, against $42,623 million a year earlier.
    UnitedHealth Group second-quarter 2026 results release, Form 8-K exhibit 99.1 - segment results, operating metrics and people served. — Q2 2026 · publ. 16 July 2026 · source ↗
  7. ReportedThe 10-K is candid about the direction: while the Final Notice for 2026 approached the expected industry forward medical cost trend, the Advanced Notice for 2027 was far below it.
    UnitedHealth Group Form 10-K for fiscal 2025 - Item 1A risk factors, competition, rate notices, reserve sensitivities and legal matters. — FY2025 · publ. 2 March 2026 · source ↗
  8. Moat Explorer calcMedicare & Retirement's share of UnitedHealthcare revenue tracks the exposure, about 49% in the second quarter of 2026.
    Moat Explorer calculation from UnitedHealth Group's reported figures ($ millions unless stated). External revenue by segment = segment revenue less affiliated revenue (10-K segment notes): 2021 UnitedHealthcare 222,899; Optum Health 54,065 - 29,234 = 24,831; Optum Insight 12,199 - 7,867 = 4,332; Optum Rx 91,314 - 55,779 = 35,535; total 287,597. 2022: 249,741; 71,174 - 40,883 = 30,291; 14,581 - 9,288 = 5,293; 99,773 - 60,936 = 38,837; total 324,162. 2023: 281,360; 95,319 - 57,696 = 37,623; 18,932 - 10,896 = 8,036; 116,087 - 71,484 = 44,603; total 371,622. 2024: 298,208; 105,358 - 63,883 = 41,475; 18,757 - 11,881 = 6,876; 133,231 - 79,512 = 53,719; total 400,278. 2025: 344,903; 101,957 - 63,615 = 38,342; 19,417 - 12,948 = 6,469; 154,726 - 96,873 = 57,853; total 447,567. Q2 2026 (2026 basis): 86,017; 23,472 - 14,353 = 9,119; 5,402 - 3,556 = 1,846; 38,292 - 23,242 = 15,050; total 112,032; Optum external 9,119 + 1,846 + 15,050 = 26,015. Optum external revenue = Optum revenue less corporate eliminations: 155,565 - 90,867 = 64,698 (2021); 182,768 - 108,347 = 74,421 (2022); 226,635 - 136,373 = 90,262 (2023); 252,957 - 150,887 = 102,070 (2024); 270,620 - 167,956 = 102,664 (2025); 102,664 / 102,070 - 1 = 0.6%. Optum revenue from inside the group: 90,867 / 155,565 = 58.4%; 108,347 / 182,768 = 59.3%; 136,373 / 226,635 = 60.2%; 150,887 / 252,957 = 59.6%; 167,956 / 270,620 = 62.1%; Q2 2026 39,648 / 65,663 = 60.4%. Affiliated shares 2025: Optum Health 63,615 / 101,957 = 62%; Optum Insight 12,948 / 19,417 = 67%; Optum Rx 96,873 / 154,726 = 63%. Affiliated revenue as share of UnitedHealthcare revenue 167,956 / 344,903 = 49%. Segment shares of consolidated revenue 2025: UnitedHealthcare 344,903 / 447,567 = 77%; Optum Rx 57,853 / 447,567 = 12.9%; Optum Health 38,342 / 447,567 = 8.6%; Optum Insight 6,469 / 447,567 = 1.4%. Q2 2026 UnitedHealthcare 86,017 / 112,032 = 76.8%. Compound growth 2021-2025: UnitedHealthcare (344,903 / 222,899)^(1/4) - 1 = 11.5%; Optum Rx external (57,853 / 35,535)^(1/4) - 1 = 13.0%. Segment margins: UnitedHealthcare 11,975 / 222,899 = 5.4% (2021), 14,379 / 249,741 = 5.8% (2022); Optum Rx 4,135 / 91,314 = 4.5% (2021), 4,436 / 99,773 = 4.4% (2022); Optum Insight 3,398 / 12,199 = 27.9% (2021), 3,588 / 14,581 = 24.6% (2022); Optum Health H1 2026 2,331 / 47,581 = 4.9%. Optum earnings decline 16,703 - 9,539 = 7,164, 7,164 / 16,703 = 42.9%. Optum Health H1 2026 revenue 47,581 / 49,562 - 1 = -4.0%; earnings 2,331 / 1,840 - 1 = +26.7%; affiliated revenue Q2 14,353 / 15,845 - 1 = -9.4%. Optum Health 2025 recast margin -1,115 / 100,051 = -1.1%; 2024 6,902 / 103,516 = 6.7%. Medical care ratio 2015-2019 from EDGAR XBRL medical costs / premiums: 103,875 / 127,163 = 81.7%; 117,038 / 144,118 = 81.2%; 130,036 / 158,453 = 82.1%; 145,403 / 178,087 = 81.6%; 156,440 / 189,699 = 82.5%. Premiums 127,163 (2015) and 257,157 (2022). Operating earnings 11,021 (2015, XBRL). One point of medical care ratio on 2025 premiums: 352,229 x 1% = 3,522; 3,522 / 18,964 = 18.6% of operating earnings. Q2 2026 favorable development 860 / 86,956 premiums = 1.0 point. Membership: commercial risk-based 8,845 - 7,655 = 1,190 thousand, 1,190 / 8,845 = 13.5%; Medicare Advantage 8,445 - 7,565 = 880 thousand, 880 / 8,445 = 10.4%; Medicaid 7,845 - 6,780 = 1,065 thousand, 1,065 / 7,845 = 13.6%; Part D stand-alone (3,315 - 2,710) / 3,315 = 18.3%. Community & State revenue per year-end Medicaid member 75,004 / 7.845 = 9,561 dollars (2023); 94,390 / 7.380 = 12,790 dollars (2025). Optum Rx quarterly scripts (414 - 387) / 414 = 6.5%. Optum Insight backlog: external 32.8 - 12.5 = 20.3 bn (2024), 31.1 - 12.9 = 18.2 bn (2025), change -10.3%; affiliated share 12.5 / 32.8 = 38%, 12.9 / 31.1 = 41%. Cyberattack provider loans 9,033 - 4,514 - 1,680 = 2,839 not yet repaid at end-2025. Market value against peers: 108.78 + 86.37 + 70.16 + 45.67 + 30.59 + 10.07 = 351.64 bn; 338.03 / 351.64 = 96%. CMS premium revenue 44% x 447,567 = 196,929 (about 197 bn); all other 447,567 - 196,929 = 250,638. Medicare & Retirement share of UnitedHealthcare revenue Q2 2026: 42,390 / 86,017 = 49.3%. Premiums share of revenue Q2 2026: 86,956 / 112,032 = 77.6%. Capital returns 2025: dividends 7,916 + buybacks 5,545 = 13,461; 13,461 / 12,056 = 112% of net earnings; free cash flow 19,697 - 3,622 = 16,075; 13,461 / 16,075 = 84%. Goodwill 44,453 (2015, XBRL) and 110,499 (2025); goodwill plus other intangibles 110,499 + 20,474 = 130,973; 130,973 / 309,581 = 42.3% of assets. Long-term debt 25,331 (2015, XBRL). Interest expense / operating earnings: 3,246 / 32,358 = 10.0% (2023); 4,002 / 18,964 = 21.1% (2025). Rate sensitivity net 345 - 273 = 72. Investment income (3,920 - 5,202) / 5,202 = -24.6%; 4,089 / 371,622 = 1.1% of 2023 revenue. Net interest-bearing debt: 6,069 + 72,320 - 28,121 = 50,268 (Dec 2025); 3,827 + 69,501 - 31,468 = 41,860 (Jun 2026). 2025 guidance: original adjusted EPS midpoint (29.50 + 30.00) / 2 = 29.75; April (26.00 + 26.50) / 2 = 26.25; actual 16.35 / 29.75 - 1 = -45%. 2026 adjusted EPS midpoint (19.50 + 20.00) / 2 = 19.75. Progress vs 2026 guidance: operating earnings 16,981 / 25,450 = 66.7%. Q2 2026 operating earnings 7,991 / 5,150 - 1 = +55%. Gross segment revenue 2025: 344,903 + 101,957 + 19,417 + 154,726 = 621,003; less Optum eliminations 5,480 and corporate eliminations 167,956 = 447,567. Medical costs 313,995 / 264,185 - 1 = 18.9%; medical costs payable 39,337 / 34,224 - 1 = 14.9%. Commercial risk-based members 8,165 - 7,725 = 440 thousand (Q1 2026), 7,725 - 7,655 = 70 thousand (Q2 2026). Medicaid 7,380 - 6,780 = 600 thousand (six months to June 2026); 7,845 - 7,380 = 465 thousand (2023-2025). Optum Rx Q4 2025 share of year 2,885 / 7,193 = 40%. Goodwill 110,499 - 106,734 = 3,765. Total debt 6,069 + 72,320 = 78,389. Dividend at 9.28 x 897.6 million shares = 8,330, 8,330 / 16,750 = 50%. Year-end P/E 2015-2020: 19.3, 21.7, 20.2, 20.0, 20.1, 21.6 (market value / net earnings). H1 2026 medical care ratio 148,847 / 174,517 = 85.3%. Part D stand-alone 2,740 - 2,710 = 30 thousand (Q2 2026). Rounded external revenue ($bn): Optum Rx 35.5, 38.8, 44.6, 53.7, 57.9 (2021-2025), 15.1 (Q2 2026); Optum Health 24.8, 30.3, 37.6, 41.5, 38.3, 9.1 (Q2 2026); Optum Insight 4.3, 5.3, 8.0, 6.9, 6.5, 1.8 (Q2 2026); Optum 64.7, 74.4, 90.3, 102.1, 102.7; net debt 50.3 and 41.9; total debt 78.4; UnitedHealthcare revenue 222.9, 249.7, 281.4, 298.2, 344.9. Optum 2026 guidance 13,450 / 9,539 - 1 = +41%. Corporate eliminations Q2 39,648 / 41,712 - 1 = -4.9%. Net interest-bearing debt / total equity 50,268 / 100,090 = 0.50. Valuation: 2026 net margin implied by guidance 16,750 / 439,000 = 3.8%; 2023 net margin 6.0% x 439.0 bn = 26.3 bn; 338.03 / 26.34 = 12.8 times - external revenue by segment, internal revenue shares and concentration. — 2015-2026 · publ. September 2026 · source ↗
    Method: Arithmetic on figures reported in UnitedHealth Group's Forms 10-K and 10-Q, results releases, SEC EDGAR XBRL and market data; operands shown in the source line.
Sources
Generated September 26, 2026