The ICR of Kanawha carries a negative outlook. The affirmation of the ratings on Humana's American subsidiaries was based on sturdy membership growth during 2012. The company's organic growth, membership gains through acquisitions, incremental Medicare membership allotted by the Centers for Medicare and Medicaid Services ( CMS ) and increase in prescription drug membership led to the surge in membership. Moreover, Humana has a trend of reporting strong underwriting gains and positive earnings. The company also has a strong inorganic growth strategy and is following an integrative care initiative that aims to expand the range of services and reduce cost. However, these positive factors were offset by the downturn in earnings after the historical high in 2011, along with the business concentration risk faced by it. Nevertheless, the strong revenues, good underwriting results and steady capital growth of Humana's Puerto Rican insurance subsidiaries led to the upgrade in their rating.