Aveanna Healthcare Holdings Inc.AVAHNASDAQ
Loading
Operator: Good morning, and welcome to Aveanna Healthcare Holdings Inc. Fourth Quarter 2025 Earnings Call. Today's call is being recorded, and we have allocated one hour for prepared remarks and Q&A. At this time, I would like to turn the call over to Debbie Stewart, Aveanna Healthcare Holdings Inc. Chief Accounting Officer. Thank you. You may begin.
Debbie Stewart: Thank you, and good morning, and welcome to Aveanna Healthcare Holdings Inc. Fourth Quarter 2025 Earnings Call. I am Debbie Stewart, the company's Chief Accounting Officer. With me today is Jeffrey S. Shaner, our Chief Executive Officer, and Matthew Buckhalter, our Chief Financial Officer. During this call, we will make forward-looking statements. Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements. Additionally, on today's call, we will discuss certain non-GAAP measures we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP. A reconciliation of these measures can be found in this morning's press release, which is posted on our website, aveanna.com, and in our most recent Annual Report on Form 10-K when filed. With that, I will turn the call over to Aveanna Healthcare Holdings Inc. Chief Executive Officer, Jeffrey S. Shaner. Jeff?
Jeffrey S. Shaner: Thank you, Debbie. Good morning, and thank you for joining us today. We appreciate each of you investing your time this morning to better understand our Q4 and full-year 2025 results and how we are moving Aveanna Healthcare Holdings Inc. forward in 2026. My initial comments will briefly highlight our fourth quarter and full-year 2025 results, along with the steps we are taking to address the labor markets and our ongoing efforts with government and preferred payers to create additional capacity. I will then provide updates on the recently announced Family First Home Care acquisition and how we are thinking about 2026 strategic initiatives and our full-year 2026 guidance before turning the call over to Matt. Now, moving to highlights of the fourth quarter and full-year 2025. Revenue for the fourth quarter was approximately $662 million, representing a 27.4% increase over the prior-year period. Fourth quarter adjusted EBITDA was $85 million, representing a 54% increase over the prior-year period, primarily due to the improved rate and volume environment and continued cost savings initiatives. Revenue for the full-year 2025 was approximately $2.433 billion, representing a 20.2% increase over the prior-year period, and full-year 2025 adjusted EBITDA was $320.8 million, representing a 74.8% increase over the prior-year period. As a reminder, our fourth quarter and full-year 2025 results did benefit from the 53rd week due to our accounting calendar. As we sunset 2025, I think it is important to reflect on the three-year strategic transformation that we have successfully navigated. I am proud of the Aveanna Healthcare Holdings Inc. team of leaders, employees, and caregivers that believe in our mission and helped execute the key strategies that returned Aveanna Healthcare Holdings Inc. to our current performance. As we look forward, we remain deeply committed to our preferred payer and government affairs strategies that continue to drive our growth in all three operating divisions. As we have previously discussed, the labor environment represented the primary challenge that we needed to address to see Aveanna Healthcare Holdings Inc. resume the growth trajectory that we believed our company could achieve. It is important to note that our industry does not have a demand problem. The demand for home and community-based care continues to be strong, with both state and federal governments and managed care organizations asking for solutions that create more capacity while reducing the total cost of care. Our Q4 and full-year 2025 results highlight that we continue to align our objectives with those of our preferred payers and government partners. By focusing our clinical capacity on our preferred payers, we achieved solid year-over-year growth in revenue and adjusted EBITDA. We also experienced improvement in our caregiver hiring and retention trends by aligning our efforts with those payers willing to engage with us on enhanced reimbursement rates and value-based agreements. While we continue to operate in a challenging environment, our preferred payer strategy supports our ability to achieve normalized growth rates in all three of our business segments. Since our third quarter earnings call, I am pleased with the continued progress we have made on several of our rate improvement initiatives with both government and payer partners as well as continued signs of improvement in our caregiver labor market. Specifically, as it relates to our private duty services business, our government affairs strategy for 2025 was twofold. First, we advanced our legislative agenda to improve reimbursement rates in at least 10 states. And second, we continued to advocate for Medicaid rate integrity on behalf of children with complex medical conditions. Our strong advocacy presence with both federal and state legislatures as well as solid support from our governors across our national footprint provided significant value in 2025. As it relates to private duty services rate updates, we achieved 10 rate enhancements in 2025, which was in line with our expectations. As we reset our legislative goals for the new year, we expect to achieve high single-digit state rate enhancements for 2026. After three years of meaningful rate movement in our PDS states, we are generally in a good place as we navigate 2026 and focus on cost-of-living type rate and wage adjustments moving forward. Now moving on to our preferred payer initiatives. Our goal for 2025 was to increase the number of private duty services preferred payer agreements from 22 to 30. We added eight additional preferred payer agreements in 2025, achieving our goal of 30. Aveanna Healthcare Holdings Inc. preferred payer strategy continues to gain momentum and allows us to invest in caregiver wages and recruitment efforts to accelerate hiring and staffing of nurses for our patients. As we reset our preferred payer goals for 2026, we believe there is still ample room to grow in our current geography as well as new states that we enter through acquisitions. With that in mind, our goal for 2026 is to add eight additional agreements with a target of 38 preferred payers by the end of 2026. Additionally, our Q4 preferred payer agreements accounted for approximately 57% of our total private duty services MCO volumes. This positive momentum in preferred payer volumes continues to highlight the shift in our caregiver capacity and recruitment efforts towards our preferred payer partners. We believe this important volume metric will grow to the low 60% in 2026 as we continue to align our capacity with our payer partners. Moving to our preferred payer progress in home health. Our goal for 2025 was to maintain our episodic payer mix above 70% while returning to a more normalized growth rate. I am extremely pleased to report in Q4 our episodic mix was 78% and our total episodic volume growth was 25% compared with the prior-year period. The continued investment in clinical outcomes, sales resources, and a focused approach to growth is paying dividends with Q4 total admissions of 10,400, or 22.4% growth over the prior-year period. We ended 2025 with 45 preferred payer agreements in home health. Our dedicated focus on aligning our home health caregiver capacity with those payers willing to reimburse us on an episodic basis has led to double-digit year-over-year growth in home health total episodes and improvement in our clinical and financial outcomes. As we reset expectations in home health for 2026, we believe our episodic payer mix will remain above 75% with organic growth rates approaching double digits. We also expect to sign additional preferred payer agreements in home health and are now targeting more than 50 agreements by the end of 2026. Finally, as we have achieved our desired preferred payer model in private duty services, home health, and hospice, we are proceeding with a similar strategy in our medical solutions business. We are in the late stages of implementing our preferred payer strategy in medical solutions and believe it will be fully realized in 2026. At year-end 2025, we had 18 preferred payers, and we expect that number to grow with a target of 25 total agreements in 2026. As we achieve our desired preferred payer model, our gross margins have stabilized in our desired range as we align our clinical capacity with those payers that value our services and pay us in timely fashion. I am pleased with our Q4 volume growth of approximately 92,000 unique patients served, or positive 3.4% over the prior-year period. As we think about medical solutions revenue growth in 2026, I would expect us to remain in the mid-single-digits growth for the next few quarters and then return to double-digit growth by the end of the year. We are encouraged by our rate increases, preferred payer agreements, and subsequent recruiting results. Our business has demonstrated solid signs of recovery as we achieve our rate goals previously discussed. Home and community-based care will continue to grow, and Aveanna Healthcare Holdings Inc. is a comprehensive platform with a diverse payer base providing a cost-effective, high-quality alternative to higher-cost care settings. Now turning to our recently announced transaction to acquire Family First Home Care, a Florida-based company with a great reputation for quality in-home pediatric care. I want to extend a warm welcome to our Family First teammates. I am thrilled to continue our acquisition growth story with great companies like Thrive Skilled Pediatrics and Family First Home Care. Both companies continue to build upon the Aveanna Healthcare Holdings Inc. brand of high-quality, compassionate care in the most cost-effective setting, the comfort of our patient's home. We expect the Family First transaction to close sometime in Q2 with normal regulatory approvals. I look forward to updating you on our progress over the coming quarters. Before I turn the call over to Matt, let me comment on our strategic plan and outlook for 2026. We will focus our efforts on five primary strategic initiatives. First, strengthening our partnerships with government partners and preferred payers to create additional capacity and growth. Second, improving clinical outcomes and customer engagement scores while lowering the total cost of care. Third, implementing high-priority artificial intelligence and automation efforts to improve operational efficiency and productivity gains. Fourth, growing through acquisitions while improving net leverage and generating positive free cash flow, and finally, engaging our leaders and employees in delivering our Aveanna Healthcare Holdings Inc. mission. Based on the strength of our fourth quarter and full-year 2025 results and the continued execution of our key strategic initiatives, we anticipate 2026 revenue in the range of $2.54 billion to $2.56 billion and adjusted EBITDA in the range of $318 million to $322 million. We believe this 2026 outlook provides a prudent view considering the challenges we still face with the evolving environment and does not include the impact of the Family First acquisition. In closing, I am incredibly proud of our Aveanna Healthcare Holdings Inc. team and their dedication to executing our strategic plan while holding our mission at the core of everything we do. We offer a cost-effective, patient-preferred, and clinically sophisticated solution for our patients and families. Furthermore, we are the right solution for our payers, referral sources, and government partners. With that, let me turn the call over to Matt to provide further details on the quarter and our 2026 outlook. Matt?
Matthew Buckhalter: Thank you, Jeff, and good morning. I will first talk about our fourth quarter and full-year 2025 financial results and liquidity before providing additional details on our outlook for 2026. Starting with the top line, we saw revenues rise 27.4% over the prior-year period to $662.5 million. We achieved year-over-year revenue growth in all three of our operating divisions, led by our Private Duty Services, Home Health and Hospice, and Medical Solutions divisions, which grew by 28.1%, 27.3%, and 21.3% compared to the prior-year quarter. Consolidated gross margin was $213.3 million, or 32.2%. Consolidated adjusted EBITDA was $85 million, a 54% increase as compared to the prior year. This growth reflects an improved rate environment, increased volumes, as well as enhanced operational efficiencies. As Jeff mentioned, this year's fourth quarter included an additional 53rd week, which had a positive impact on both revenue and earnings. As a result, the current fiscal year reflects an extra week of business activity compared to a typical year. Now, taking a deeper look into each of our segments. Starting with Private Duty Services, revenue for the quarter was approximately $541 million, a 28.1% increase, and was driven by approximately 12.4 million hours of care, a volume increase of 17.9% over the prior year. Q4 revenue per hour of $43.74 was up 10.2% compared to the prior-year quarter, primarily driven by preferred payer volume growth and the rate enhancements previously discussed. We remain optimistic about our ability to attract caregivers and address market demands for our services when we obtain acceptable reimbursement rates. Turning to our cost of labor and gross margin metrics. We achieved $149.9 million of gross margin, or 27.7%. The cost of revenue rate of $31.62 in Q4 was up $3.15, or 11.1%, from the prior-year period. Our Q4 spread per hour was $12.12, reflecting continued normalization as we make ongoing adjustments to caregiver wages to support higher volumes and improve clinical outcomes. Moving on to our Home Health and Hospice segment. Revenue for the quarter was approximately $69.3 million, a 27.3% increase over the prior year. Revenue was driven by 10,400 total admissions with approximately 78% being episodic, and 14,000 total episodes of care, up 25% from the prior-year quarter. Medicare revenue per episode was $3,223, up 3% from the prior-year quarter. We continue to focus on rightsizing our approach to growth in the near term by focusing on preferred payers that reimburse us on an episodic basis. This episodic focus has accelerated our margin expansion and improved our clinical outcomes. With episodic admissions well over 70%, we achieved our goal of rightsizing our margin profile and enhancing our clinical offerings. We are pleased with our Q4 gross margin of 53.7%, representing our continued focus on cost initiatives to achieve our targeted operating model. Our Home Health and Hospice platform is dedicated to creating value through effective operational management and the delivery of exceptional patient care. Now to our Medical Solutions segment results for Q4. During the quarter, we produced revenue of $52.5 million, up 21.3% over the prior-year period. Revenue was driven by approximately 92,000 unique patients served, and revenue per UPS of approximately $570, up 17.9% over the prior-year period. Gross margin was approximately $26.2 million, or 50%, for the quarter. Medical Solutions' Q4 revenue, gross margin, and reimbursement rate benefited from a reserve release driven by stronger-than-expected cash collections on claims we had previously estimated as uncollectible. We expect results to normalize in Q1 with gross margins returning to the 43% to 45% range. As Jeff mentioned, we continue to implement initiatives to be more effective and efficient in our operations to achieve our targeted operating model. We are accelerating our preferred payer strategy in Medical Solutions by aligning our capacity with those payers that value our resources and appropriately reimburse us for the services we provide. We expect margins to normalize and UPS to accelerate its growth as we implement our targeted operating model. While I am pleased with the integration efforts to date, we are entering the final push to complete our efficiency efforts and return to sustained year-over-year volume growth in Medical Solutions. In summary, we continue to fight through a difficult environment while keeping our patients' care at the center of everything we do. It is clear that aligning caregiver capacity with preferred payers who value our partnership is the right path forward at Aveanna Healthcare Holdings Inc., and throughout 2025, with the strong momentum from Q4, we are optimistic these trends will continue into 2026. We will continue to pass through wage improvements and other benefits to our caregivers in the ongoing effort to better improve volumes. Now moving to our balance sheet and liquidity. At the end of the fourth quarter, we had liquidity of $529 million, representing cash on hand of approximately $193 million, $110 million of availability under our securitization facility, and approximately $226 million of availability on our revolver, which was undrawn as of the end of the quarter. We had $24.5 million in outstanding letters of credit at the end of Q4. On the debt service front, we had approximately $1.49 billion of variable-rate debt at the end of Q4. Of this amount, $520 million is hedged with fixed-rate swaps, and $880 million is subject to an interest rate cap which limits further exposure to increases in SOFR above 3%. Accordingly, substantially all of our variable-rate debt is hedged. Our interest rate swaps extend through June 2026, and our interest rate caps extend through February 2027. Looking at cash flow, cash generated by operating activities was $125.9 million, and free cash flow was $131 million. We are encouraged by our strong cash collections and cost efficiency efforts, which drove solid operating and free cash flow in 2025. We expect similar cash flow performance in 2026. As a reminder, the first quarter is typically our seasonal low point for both operating and free cash flow, with improvement expected throughout the rest of the year. Before I hand the call over to the operator for Q&A, let me take a moment to address our outlook for 2026. As Jeff mentioned, we expect full-year 2026 revenue in the range of $2.54 billion to $2.56 billion and adjusted EBITDA in the range of $318 million to $322 million. This guidance does not include any impact from the Family First acquisition, which we expect to close in late Q2. As outlined in our recent 8-K, we are paying $175.5 million in consideration, or approximately 7.5x post-synergy EBITDA. We plan to fund the transaction and related fees with cash on hand and our securitization facility. As we reflect on our Q4 results, I would like to take a moment to express my sincere gratitude to all of our Aveanna Healthcare Holdings Inc. teammates. These strong results would not have been possible without your hard work and dedication. Looking ahead, I am excited for the continued execution of our 2026 strategic plan and look forward to providing you with further updates at the end of Q1. With that, let me turn the call over to the operator.
Operator: Thank you. At this time, we will be conducting a question-and-answer session. A confirmation tone will indicate your line is in the question queue. You may press 2 if you would like to remove your question from the queue. As a reminder, we ask that you please limit to one question and one follow-up. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. One moment, while we poll for questions.
Operator: Our first question comes from A. J. Rice with UBS. Your line is now live.
A. J. Rice: Hi, everybody. Congratulations on the Family First acquisition. Obviously, that is a decent-sized deal for you. And I think you have said you are going to fund that with cash and short-term borrowings. How should we think about the impact that is likely to have on leverage? And can you give us any early read on whether there is accretion there, or the trajectory on the margin contribution over time?
Matthew Buckhalter: Yes, A. J., we are really excited to welcome the Family First team into the Aveanna Healthcare Holdings Inc. family. They have really strong clinical outcomes and really disciplined operations, and that makes them a really nice cultural fit and operational fit into our family. We value this transaction, as I said in the script, at about 7.5x post-synergy EBITDA. You could see that, on a very short-term basis, having a very minimal impact on our leverage profile. But with the generated free cash flow that we will produce in 2026, you should see us flat to slightly down as the year progresses. On a pro forma basis, with both of those pieces taken into consideration, we still plan on deleveraging in 2026; however, slightly—not the large jumps that you have seen in the past two years. Jeff, anything else?
Jeffrey S. Shaner: Yes, I think, A. J., it is well said by Matt. We have gotten leverage down to just right at 4x. As Matt said, we should end 2026 in that range with the Family First addition, and it is just another nice transaction. Thrive was a great transaction for us. It densified our services and allowed us to be better payer partners, with Thrive mainly in Texas. This is a Florida-focused deal for us, and it is just a nice merger of two great companies. We have to clear some regulatory hurdles over the next month or two, and are excited to get through those and get on to doing business with the Family First team. It is a really nice acquisition for us to start the year.
A. J. Rice: Okay. Just maybe as a follow-up on the preferred provider arrangements that you are doing. At this point, do you have pretty good geographic coverage across your footprint, or are there still major geographies where you do not yet have it, and is the idea that the incremental eight that you did last year, the incremental eight this year—is that more density, multiple managed care Medicaid programs that you are contracting with in a given geography, or is it still just trying to get the broad coverage?
Jeffrey S. Shaner: That is a great question. The eight we won in 2025 and the additional eight that we are anticipating for 2026 are in the current geographies that we have. I will say current geographies post the Thrive acquisition because we added New Mexico and Kansas as two additional Medicaid states. So as we think about executing on the 38-goal for this year, it is still densifying our current geographies. I would tell you, at this point, we have landed most of the major payers in the major markets, so we are rounding out some of our payer partnerships. And then I think the next steps for us, as you think about what is next for Aveanna Healthcare Holdings Inc. from a Medicaid standpoint, we still want to fill in the states like Ohio, West Virginia, Kentucky, Tennessee. That is still an open area today where we do not have any Medicaid services. So those four or five states in the heartland we really want to fill in. That is how we think about additional M&A in the back half of 2026 and going into 2027 on the Medicaid side of the business. Thanks, A. J.
A. J. Rice: Alright. Thanks.
Operator: Our next question is from Brian Gil Tanquilut with Jefferies Group. Your line is now live.
Brian Gil Tanquilut: Hey, good morning, and congrats on this acquisition. Maybe, Matt, as I think about to start, when I think of Family First, any other color you can share with us in terms of how we should be thinking about revenues—and I guess we can back to the EBITDA contribution—but just any KPIs, any metrics that you can share with us? And then kind of related to that, Jeff, is this one of those deals where clearly you are identifying Florida with a deal? Is this one that has been supported or encouraged by the payers where they have asked you in the past to go to new markets?
Matthew Buckhalter: Awesome questions, Brian. And obviously, on 2026 financials themselves, the impact will depend on the timing of closing of this, obviously. That said, we really expect this to be a really smooth and efficient integration, consistent with how the team successfully integrated the Thrive acquisition and brought that team on to the Aveanna Healthcare Holdings Inc. platform. On the revenue side, it is in the ballpark of $120 million of revenue. And then you can run the math for the 7.5x based upon purchase price. All that depending on a pro forma basis, 2026—we will see how that really lands just based upon closing timing. Jeff, you want to add on?
Jeffrey S. Shaner: Yes. Brian, I think you hit it. Thrive was right down the middle of the fairway, densifying our payer needs in Texas. This one is primarily Florida-focused. Both companies have great reputations in the Florida market today, well respected by the MCO payers. Florida is an MCO market; MCO payers are incredibly important to us. But this acquisition helps us round out the areas in Florida that we were not in, so it does give us geographic expansion within Florida. It allows us to service effectively every county in the state of Florida. And, again, our payer partners are very supportive of our growth. I think this one is right down the middle of the fairway just like Thrive. And again, excited to get through the regulatory approvals here in Q1 and Q2 and get this closed up in the latter half of Q2.
Brian Gil Tanquilut: No, that makes sense. And, Matt, any chance you can help us bridge the 2026 EBITDA given I think you have, like, almost roughly $20 million of one-timers in 2025, there is an extra week, and then there is Thrive in there. So just trying to get that bridge and the guidance from 2025 actuals.
Matthew Buckhalter: Yes. So on the EBITDA, Brian, take that roughly $320 million. We came out earlier this year and talked about, hey, bridge that back down to the $300 million based upon the retro rate increases, the cash collections, and that 53rd week itself. So really your jumping-off point should be around that $300 million, going up to that range of $320 million as we currently sit organically without any M&A inclusive in there. On the revenue side of things, the 53rd week and Thrive do a really nice offset to one another—within 20 basis points themselves. And so we are still going to be in that 5%+ organic revenue growth as we currently sit today. But that is back in line with our normal expectations, that 5% to 7% range on revenue and that high single digits or mid- to high-single digits on EBITDA. So back into a normalized idea of Aveanna Healthcare Holdings Inc.
Jeffrey S. Shaner: And, Brian, the thing I will add to that is what Matt said is on the EBITDA growth implied about 7%. Again, we tried to, in my comments, lay out that we expect our PDS government rate wins to be sub-10 this year. Last year, we landed right at 10, and that is a net number from positive and negative increases. So we expect that number to land somewhere between six and eight state rate increases this year, and we expect them to be more cost-of-living oriented. So I will call it the 1% to 5% Medicaid rate wins—less number of total wins, less percentage per win—that is really what we are factoring into our guidance as we start the year. I think as we get to May, close Q1, close Family First, we will have a much better feel for how the year plays out, especially with our legislative efforts being in session right now in the first half of the year.
Brian Gil Tanquilut: Awesome. Thanks, guys.
Jeffrey S. Shaner: Thanks, Brian.
Operator: Our next question comes from Raj Kumar with Stephens. Your line is now live.
Raj Kumar: Hi. Good morning. Maybe just focusing on the preferred payer arrangements and thinking about the Home Health and Hospice book. I guess maybe thinking about you see an episodic mix trending above 75%. And I think you have previously hinted you would not be surprised if it got as high as 80%. So maybe just thinking about what is embedded into 2026. And then maybe just any framing around any membership impacts given how volatile the membership was during AEP on the Medicare Advantage side. Just any color on that would be helpful.
Jeffrey S. Shaner: Yes, Raj. Great question. And I am going to take that as a compliment to our Home Health and Hospice business. Like you, we are incredibly proud of their results. I think we mentioned it—pushing 25% organic year-over-year admission and episodic growth is, I would tell you, first-class, best-in-class results. And they have done it from just blocking and tackling. They have done it from just being really good at providing great clinical outcomes and the right level of care to the right payers and the right patients. So we are really robust. Now that we have got a more clear path from a federal home health rate standpoint, we continue to lean in. This is an area that we want to grow through both organic and inorganic M&A-related activities this year. Clinical outcomes are almost four and a half stars on average for our home health locations—I think it is 4.3 stars where we sit today. Gross margins in the 53% to 54%, great cash collections. As you said, episodic mix approaching 80%, and we are growing north of 10% year over year—right now 20%. We are off to a great start to the year in Q1. These teams are having a great start to the year. So I think everything we would say is we are going to continue to lean into home health and continue to grow it. My concern with the trends of managed Medicare? No. I think we are doing our playbook in this business, and our team is just kicking butt and taking names right now. So we are really excited about where we are as we ended 2025 and, equally important, as we sit here kind of halfway through Q1—really excited about what these teams have done for the business model.
Raj Kumar: Got it. And then maybe just on the Medical Solutions business, 2025 was a year of optimization around preferred payer strategies. As we think about 2026 and given where the reimbursement dynamics were, any kind of framing around what would be an appropriate run rate when we exclude the reserve dynamics favorability in the quarter?
Debbie Stewart: Yes, Raj, you called it out. During the quarter, gross margin and the revenue reimbursement rate were elevated, and that was from a reserve release that we recorded driven by improved cash collections on previously reserved claims. Without the inclusion of that reserve release, the Medical Solutions gross margin was slightly elevated compared to our guide, but we do expect it to normalize in Q1, getting back to that 43% to 45% range.
Matthew Buckhalter: Yes. Well said, Debbie. And to put the dollars in there, those contributed $2.5 million to $3 million of additional revenue and EBITDA in the quarter. So not overly material to earnings, but it shows up in the Medical Solutions metrics and gross margin just due to its size. On the modernization efforts, though, Raj, we are really excited about what the team has been able to do and what they have accomplished so far. As we move into 2026, we expect to see preferred payer numbers significantly increase. Currently, we are sitting at 18. We expect that to continue to grow as we become better aligned and put our capacity with those who support us. There is a little bit of work to do at the same time. So we plan on wrapping this up in the front half of 2026, and that is when you will see us return back to a double-digit growth number organically in this business, and gross margins, as Debbie pointed out, sustaining in that 43% to 45% range.
Raj Kumar: Great. Thank you.
Operator: Our next question is from Ben Hendrix with RBC Capital Markets. Your line is now live.
Ben Hendrix: Hi. This is Drew Starritt on for Ben Hendrix. You have previously mentioned continued wage pass through into 2026. Can you quantify the magnitude and timing of these increases?
Matthew Buckhalter: Yes. Drew, I think the way to look at it is that spread rate that we talk about a lot. Q4 was at $12.12, which is coming back down in line. But we have continued to push through wages. As we talked about the entire year in 2025, we had some initiatives in place to really drive our volumes, and you see it impacting and really growing our volumes. This really came down, and you can see it in our gross margins. We settled in that 28% range, which was on the higher end of the range that we give for that business and in line with our expectations. Looking ahead, we will continue to actively manage spread, as we do every single day, to meet the needs of our preferred payers and our payer partners.
Drew Starritt: Got it. Thank you.
Operator: Our next question comes from Benjamin Michael Rossi with JPMorgan. Your line is live.
Benjamin Michael Rossi: Good morning. I appreciate you taking my questions and appreciate the earlier comments regarding your state contracting. I guess shifting focus to California, which still seems to be the outlier here on home-based nursing rates, what do you think is the realistic 2026–2027 scenario for California here between, call it, no change, the cost-of-living type increase in that 1% to 5% range, or maybe a structural reset? And then under each of those scenarios, do you have any commentary on impact to your PDS spread rate per hour or maybe your broader market share strategy given your stance to not exit California?
Jeffrey S. Shaner: Yes. Thanks, Ben. We met with the Governor of California as early as last week. We are not in the budget. There is no PDN rate increase in the 2026–2027 budget for California as it exists today. We are still lobbying and advocating to be in the May—what is called the May Revised—budget. If I am scoring that as a handicap, I would say it is less than 10% or 15% that PDN makes it in any shape, way, or form in the California budget. We are certainly not expecting it, and we have not modeled that. Over time, I hate to say it, but as our other markets have grown at the 20%, 22%, 25% year-over-year growth rate in PDS, California has unfortunately just gotten smaller and smaller from a materiality standpoint for the company. We still care deeply about our California patients. We still care deeply about California operations. We advocate very hard. Like I said, we met with the governor last week, and we continue to meet with his staff and push forward. But today, as it sits today, I am not expecting any material change that will stopgap. A cost-of-living increase is potential, but I would say is unlikely. There is nothing baked in our guidance that California has a change in heart in 2026.
Benjamin Michael Rossi: Understood. Thanks for the additional comments there. I guess just as a follow-up, we have heard from some other healthcare facilities names regarding spillover impact from some of the delayed respiratory season and then some of the additive weather-related pressures from some of the winter storms. When you think about your 2026 outlook, how are you factoring any of the respiratory or weather-related impacts during Q1? Thanks.
Jeffrey S. Shaner: That is well said. We did not put it in our prepared remarks, but we have had to fight through—like all of our peers—mainly snow and significant snow throughout the entire country. I would love to say the Northeast, but everything from Texas all the way up through Maine. Our team is doing a good job fighting that through. We have a no-excuse mentality here at Aveanna Healthcare Holdings Inc. We just fight through everything that comes our way. I do not think we changed our guidance based on weather. But like our peers, we have had to fight through two or three weeks of weather in the first ten weeks of the year. I will not say it was nothing, but it is just something we handle. We move on, and we are glad weather for the most part is behind us at this point and back to business. So I do not think it will have any material impact. Matt mentioned in his prepared comments, as a reminder, Q1 is our largest payroll tax quarter. So keep in mind as you think about guidance, Q1 is seasonally low for our margin, mainly driven by the payroll tax on our labor cost. Thanks, Ben.
Operator: Our next question comes from Andrew Mok with Barclays Bank. Your line is now live.
Andrew Mok: Hi, good morning. Given the recent increase in oil prices, can you remind us how much travel is reimbursed for your caregivers and how much fuel represents as a percentage of total revenue and total cost? Thanks.
Jeffrey S. Shaner: Hey, Andrew. Good morning. Great question. Eighty percent of our revenues are driven off of shift care in the home where we do not reimburse any form of mileage or fuel. It is primarily because our nurse goes from his or her home right to the home of the patient. They are there for eight or ten or twelve hours, and they go home. So the vast majority of the business at Aveanna Healthcare Holdings Inc. has zero tied to gas prices from a reimbursement standpoint. Our Medical Solutions has some impact on a minimal amount from our drivers. The business that it does impact is our Home Health and Hospice business, and that is about 12% of our total revenue. So it is not a nothing impact for us, but thankfully, with the size and scale that we are and the diversity of our payer mix and our business mix, it is not as meaningful as it would be to some of our large home health and hospice peers.
Andrew Mok: Got it. Maybe just as a follow-up, can you provide a little bit more color on the pace of pass through to caregivers on PDS and how you expect the spread to materialize throughout the year?
Matthew Buckhalter: Yes, Andrew. I would go back to the gross margin line item here—27.7% in Q4. A little bit of PTO utilization, holiday pay, etc., occurs in Q4, so a little bit of extra compression in there. But our range should be in that 27% to 28% gross margin for the Private Duty Services segment. We are close to it now. As we continue to drive reimbursement rates—as Jeff mentioned, single high digits on the government affairs side—as we continue to add eight more preferred payers, as we continue to organically grow our preferred payers, we will take those rate wins and be able to continue to push them down to our caregivers, still aligning to that 27% to 28% gross margin.
Jeffrey S. Shaner: Thanks, Andrew. We appreciate it.
Operator: Our next question comes from Pito Chickering with Deutsche Bank. Your line is now live.
Pito Chickering: Hey, good morning, guys. If I think about the PDS business model, the preferred payer strategy makes a ton of sense just due to the pretty large savings for managed Medicaid, and obviously it is more of a niche market. But about home health—it is a huge market with a lot of nurses employed. Can you just walk us through why you can replicate the preferred payer strategy in the home health segment?
Jeffrey S. Shaner: Good morning, Pito. I think, one, our discipline around episodic payer mix. A year or two ago, people questioned whether or not being above 70% was attainable long term. I would say at this point, we have put that behind us and said being above 75% is our long-term strategy. Over time, payers have come around. At first, payers did not like the episodic conversation three, four, five years ago, but when you do not bend your backbone and you keep your clinical capacity focused on the right payer base—meaning episodic payers—eventually we have found that our payers do come back around. Clinical outcomes drive the story. Great clinical outcomes lead to good financial outcomes. In our Home Health and Hospice business—specifically home health—we have been able to stand behind great clinical outcomes. I think that when you look at eight quarters in a row being above 75% and we are approaching 80% now on an episodic basis, at this point, this is the business model. We are not moving from it, and our payers have caught up to us. I want to give a shout to our payer team. We have a world-class payer team, and our home health and hospice payer leader has done a fantastic job. She has been amazing. Kudos to our payer team. They are out every day continuing to beat the drum, but they will not take fee-for-service, low-dollar contracts because of how valuable caregivers and clinicians are in today’s world. Thank you for noticing, by the way.
Pito Chickering: Okay. Fair enough. And then one more on Family First. How much of the $120 million of revenues are in Florida versus the other six states? And how fast can you roll out the preferred payer strategy in Florida in those new markets? And as I think about the opportunity there, I assume it is more acceleration of the $120 million of revenues versus a around 20% margin business that the business has today?
Jeffrey S. Shaner: Yes. Think of the revenue base being two-thirds Florida, one-third everywhere else. Certainly, Florida is the state that we focused on. They do have meaningful business in other states outside of Florida, but Florida is where we focused and what made the most strategic rationale. They have really good relationships in the state of Florida today from a payer standpoint. We have very good relationships as well. The feedback we have gotten early from the payers is very supportive and congratulatory on the standpoint of providing more cost-effective, patient-preferred, win-win type scenarios. At the end of the day, these are two great companies, both providing great care. It is not like Aveanna Healthcare Holdings Inc. is superior in its service. Family First does a really nice job providing care in their seven states. We think this is good for patients. We think this is good for employees. This is good for payers. It will take us a little bit of time. As we saw with Thrive, it takes about a half a year or so to get through the integration-related efforts—systems, back office, benefits—to then really get to the expansion of care. We hope Family First will close at some point in mid to late Q2, and by the end of the year, we are wrapping up Family First. I want to hit on again: we are committed to growing our Home Health and Hospice business through accretive M&A. I think you will see us get back to the home health focus—both de novo and tuck-in M&A.
Pito Chickering: Great. Thanks so much, guys.
Operator: Our next question comes from John Ransom with Raymond James. Your line is now live. Hey, there.
John Ransom: So if we think about the core EBIT growth this year being just below 7% on a consolidated basis—$318 million to $320 million-ish—how does that look by segment? What are the highest growth segments versus the lowest growth segments of your tree as we think about modeling?
Matthew Buckhalter: Historically, Medical Solutions and Home Health and Hospice have been our highest organic growth segments, John. We have Medical Solutions going through its modernization efforts at this time. We talked about low single-digit growth in the front half of 2026 but returning to high single digits to double-digit growth in the back half of 2026. There is a little bit of mutedness in H1 compared to H2. Home Health and Hospice is hitting out of the gate strong just as they finished the year strong. That will continue to be at high single digits to double digits growth. We think PDS returns back into the normalization—3.5% to 4% volume growth—add in a point to a point and a half of rate growth, getting back to your 5% to 7% kind of range itself, or 3% to 5% on the upper end of that one. That is how we have it modeled out and how we are thinking about it in 2026 and beyond.
Jeffrey S. Shaner: And, John, just being cost-effective and efficient in the back office, corporate office—we are down to 4.5% corporate cost as a percentage of revenue. We think we can keep making that a little better. You were about to bring this up, so I want to highlight generating a meaningful amount of cash flow. I appreciate you highlighting that great point. That $131 million of free cash flow last year was well beyond our expectations, and really kudos to Matt and Debbie and the team for executing on that. Generating that kind of cash moving forward just gives us optionality to continue to do deals like Family First and to use cash. We are excited about the opportunity to do that. Thanks for asking.
John Ransom: You are welcome. The other question is just the PDS rate outlook. I mean, you are adding eight preferred payers, but you are only calling for 1% to 1.5% rate. Is that conservative, or are we missing something?
Jeffrey S. Shaner: No. I think it shows how far along the spectrum we are in the strategy. When we first started, we were getting 10% of volume, 15% of volume. Some of these now we are tucking in are smaller in nature. They are still niche oriented. They are really important. Even a 1% volume mover, if we can move it into a preferred payer, matters. Think of us being further along the maturity spectrum in preferred payers, which is why we love the idea of additional states because it opens up new markets for us. As we think of Thrive, New Mexico and Kansas were so important because they opened up two brand new MCO markets for us. As we think of preferred payers going from 30 to 38, we are continuing to round out some of those final tweaks in our current markets and really focused on new expansion.
John Ransom: Yeah. Last one for me. I know we are a little over time. If we think about the synergy between the nutrition segment and the pediatric segment, but I think about home care, hospice, and personal care—the market is kind of mixed. Is there really that much synergy between the three businesses? Does it help you with payer? Does it help you with nurse recruiting? What is the synergy? And I guess where I am going—with hospice M&A multiples being in the teens—if somebody came to you with a 15x multiple offer for your hospices, is that something you would consider, or do you really think you want to knit all these pieces together?
Jeffrey S. Shaner: It is, first of all, a very thoughtful question. I will say this. Yes, obviously, the enteral nutrition business is incredibly synergistic to the PDS business. They operate as a referral entity incredibly well together. We have a lot of crossover in the referral source and the payer conversations between those two businesses. The opposite is true between our PDS and our HHH business. There is very little synergy from a referral source standpoint—even a payer standpoint—they are very different conversations, as you know. Why we love being in both businesses—one, the diversification. As we see right now, the last three years, Medicaid has been the darling. Right now, it is swinging back to Medicare being more the darling. We like the idea of being larger in both of these businesses, and we would like to be larger in the HHH business over time. We think of growth rates where businesses like home health and hospice can grow in double-digit year-over-year organic growth. We like that from a growth algorithm. We are committed to all three segments, excited about all three segments. We just want to get back to blocking and tackling this year and being really good at executing our business plan. Thanks, John.
Operator: We have reached the end of the question-and-answer session. I would now like to turn the call back over to Jeffrey S. Shaner for closing comments.
Jeffrey S. Shaner: Thank you, operator, and thank you for your attention. We look forward to catching up in mid-May on our Q1 2026 results. Thank you, and have a wonderful day.
Operator: This concludes today's conference. You may disconnect your lines at this time, and we thank you for your participation.