SPARK Senior Health · Investment Book · Stage 3 of 5
Financial Model
Revenue architecture, 10-clinic P&L, capital structure & investor returns
§3.1
Reimbursement Schedule
2026 CMS MPFS rates · NP ×0.85 · bottom-up PMPM
→
§3.2
Member Ramp
18-month per-clinic ramp · 10-clinic portfolio
→
§3.3
Expense Model
Per-clinic ops · MSO overhead · tech stack
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§3.4
5-Year P&L
Revenue · expenses · EBITDA · net income
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§3.5
Capital Structure
$4M–$5M raise · single tranche · deployment timeline
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§3.6
Investor ROI
Returns · exit scenarios · MOIC analysis
→
Scenario
25% pen · 18-mo ramp
Single Raise
$4M · M1 · Lease
$5M · M1 · Owned
Portfolio PMPM
~$140 net · $163 gross (Y5)
Y5 Net Revenue
~$18.6M (Y5)
↓Begin
Stage 3 · Financial Model · Section 3.1
Revenue Model — Reimbursement Schedule
2026 CMS MPFS rates at NP 85% billing factor · Duals segmented into FFS-accessible tiers · D-SNP excluded Year 1–2.
§ 3.1CMS MPFS 2026 · CF $33.40
GA Locality 03 · NP 85%
✓ Tier 1 — Standard FFS
FFS Medicare Only
Full 2026 MPFS rates. Bill Medicare 80% + patient owes 20% coinsurance. No write-offs. Highest net revenue per visit. 50%–70% have Medigap or employer-sponsored Part B coverage.
PMPM: ~$140 net (Y5)
✓ Tier 2 — SLMB Duals
SLMB Members
Medicaid pays Part B premium only. Patients owe full coinsurance same as Tier 1. Bill identically to standard FFS. No write-off required.
PMPM: Same as Tier 1
✓ Tier 3 — QMB Duals
QMB Members (~30% of panel)
Federal law: write off 20% coinsurance on visits/ancillary entirely. CCM/APCM/RPM unaffected — no patient cost-sharing on these codes. Higher complex CCM mix (avg 4+ chronic conditions).
Write-off: visit/Dx only · CCM/RPM = full rate
✗ Tier 4 — D-SNP · Phase 3+
D-SNP Duals
Enrolled in MA D-SNP plan. Require individual plan contracts — not accessible via direct CMS billing. Excluded from Year 1–2 model. NE GA HMO penetration is <4% — D-SNP volume is very small.
Excluded · Phase 3+ plan contracting
Visit & Professional Revenue — 2026 NP Rates
NP 85% · Palmetto GBA J-J MAC
G0438 · AWV Initial
Per member per year · first year · attribution anchor
~$148
G0439 · AWV Subsequent
Annual · care plan update
~$117
G2211 · Longitudinal Add-On
Appended to qualifying E&M / AWV · 70% of visits
~$14
99212/99213 · E&M Established (level 2/3)
Most common visit type · chronic f/u
~$51 / ~$81
99214 / 99215 · E&M Established (level 4/5)
Complex chronic management
~$109 / ~$155
99203 / 99204 · E&M New Patient
First visit · new patient intake + AWV same day
~$97 / ~$142
99495 · TOC Moderate (14-day)
Post-discharge follow-up · 60% of TCM volume
~$187
99496 · TOC High (7-day)
High complexity discharge · requires face-to-face
~$254
Visit ramp: 2.0 visits/member/yr in clinic Year 1 → linear ramp months 13–24 → 4.0 visits/member/yr from clinic Year 3 (steady state). Each clinic runs its own ramp clock independently.
Care Management — APCM & CCM 2026 Rates
Billed to Medicare only · no patient cost-sharing
G0558 · APCM QMB/Dual 2+ chronic
~30% of panel · 60% enroll · 92% billing success
~$99/mo
G0557 · APCM Standard FFS 2+ chronic
~15% of panel · 60% enroll · 92% success
~$45/mo
G0556 · APCM Low acuity 0–1 chronic
~8% of panel · 60% enroll · 95% success
~$14/mo
99490 · CCM non-complex ≥20 min
55% of CCM panel · ~45% of panel total
~$56/mo
99487 · CCM complex ≥60 min
10% of CCM panel · 82% billing success
~$123/mo
99439 · CCM add-on 20 min
No monthly limit on units
~$43/mo
RPM — 2026 Codes & COGS
Tenovi 4G cellular · $40 device COGS/enrolled/mo · 85% hit 16-day threshold
99454 · Device supply 16+ days
85% of enrolled hit 16-day threshold
~$44/mo
99445 · Device supply 2–15 days (NEW 2026)
15% of enrolled — partial month · same rate as 99454 (CMS equalized tiers)
~$44/mo
99457 · Treatment mgmt first 20 min
88% compliance × 85% full-length tier · interactive communication required
~$44/mo
99458 · Treatment mgmt add-on 20 min
40% of the 99457 group · no monthly limit
~$35/mo
COGS deducted: $40/enrolled RPM member/month (Tenovi device + 4G data). Deducted directly against RPM gross revenue in model. Net RPM after COGS: ~$50/enrolled/month at full maturity.
Blended PMPM Architecture
Revenue per member per month, summed bottom-up from billing codes (no ceiling or multiplier). Base scenario: 25% FFS penetration, 18-month ramp, 2.0→4.0 visits/member/yr. A 2.5% claim denial write-off is applied to gross revenue.
~$30
E&M Visits
(4.0/yr steady state)
~$41
CCM / APCM / PCM
(recurring monthly)
~$21
RPM net
(after $40 COGS)
~$140
Net PMPM
Y5 average
Stage 3 · Financial Model · Section 3.2
Member Ramp — 18-Month Per-Clinic Ramp · 10-Clinic Portfolio
Conservative 18-month linear ramp per clinic from first patient to full panel (FFS pool × 25%, no member cap). Each clinic runs its own independent ramp clock. Portfolio grows as new clinics open per the 3-year expansion sequence.
§ 3.218-month ramp · 25% pen
Panel = FFS × 25% (644–1,527)
10 clinics · Y1–Y3
Per-Clinic Enrollment Phase Milestones
Month 1 → 18 per clinic · independent clock · transport enables faster ramp vs mobile model
Pre-Launch · Months −3 to 0
0 members · formation & buildout
Lease execution, ADA buildout, PECOS enrollment (90-day lead), staff hire sequence, EHR go-live, community partner outreach to churches and senior centers.
Revenue: $0 · Capital draw phase
Pilot · Months 1–6
First visits → CCM enrollment begins
AWV at first visit establishes attribution. CCM consent + care plan within 30 days. RPM devices provisioned. First CMS claims submitted ~Month 1–2. First CMS payments arrive 30–45 day lag. Transport van in daily operation.
Revenue ramp: ~$10K → ~$55K/mo
Scale · Months 7–12
CCM/APCM/RPM enrollment accelerates
Care coordinator adds panel management capacity. APCM and CCM enrollment at 60% of eligible members (decided at first visit). RPM threshold compliance at 88%. Additional NP hired when NP utilization crosses 85% (Habersham adds a part-time NP ~Month 16).
Revenue ramp: ~$60K → ~$100K/mo · clinic-level EBITDA positive since ~Mo 2 (~$36K/mo by Mo 8)
Maturity · Months 13–18
Full panel · FFS pool × 25% (e.g. 1,267 at Habersham)
Visit rate ramps from 2.0 to 4.0/member/yr (months 13–24). Net PMPM settles ~$130. E&M, CCM, APCM, RPM at steady state. Ancillary = labs, rapid tests, vaccines, RPM (POCUS not yet modeled).
Terminal revenue (Habersham): ~$165K/mo at M18 · ~$2.0M/yr annual run rate
Portfolio Enrollment Trajectory
10 clinics · 25% FFS penetration · 18-month ramp per clinic · no member cap
Year
Active Clinics
Members (EOP)
Net Revenue
Y1
3 (Habersham, Lumpkin, Stephens)
1,737 (ramp phase)
$1.41M
Y2
6 (+White, Rabun, Union)
5,039
$5.74M
Y3
10 (+Fannin, Gilmer, Gordon, Chattooga)
9,105
$11.79M
Y4–5
10 (steady state · no new clinics)
11,097 (full maturity)
$17.0–18.6M
Per-Clinic Terminal Economics (Base)
Habersham (flagship) at ramp completion · 1,267 members · Month 18 of clinic life
Enrolled members (5,066 FFS × 25%)1,267
Monthly net revenue~$165K
Annual run rate~$2.0M/yr
Terminal net PMPM~$130
Clinic-level EBITDA breakeven~Month 2 of clinic life
Per-clinic ops (annual)$157,218/yr
Annual CMS savings documented~$10.6M/yr (at 1,267 members × $8,400)
Enrollment Mix at Terminal State (Per Clinic)
Habersham · 1,267 members · base scenario · APCM/CCM/RPM program enrollees
G0558 APCM enrolled
~227 QMB/Dual members · ~$99/mo · ~$20.7K/mo
CCM enrolled (99490/99487)
~340 members · ~$56–123/mo · ~$22K/mo
G0557/G0556 APCM enrolled
~159 members · $45/14 per mo · ~$5.8K/mo
RPM enrolled
~530 members (42.1%) · ~$50 net/mo · ~$26K/mo
Stage 3 · Financial Model · Section 3.3
Expense Structure — Clinic + MSO + Tech
Three cost layers: per-clinic operations (demand-driven clinical staff + fixed clinic ops), MSO overhead (central leadership + operations), and dynamic tech stack (scales with clinics, members, providers, and revenue).
§ 3.3Per-clinic ops: $157,218/yr
Driver: $45,000/yr
MSO Y1: $1,572K total
Per-Clinic Operating Costs
$157,218/yr per active clinic · excludes clinical staff & driver
Clinic lease (~2,200 sq ft)$30,000/yr (Lease mode)
Malpractice insurance$12,000/yr
Supplies + consumables (exam, lab)$24,000/yr
Utilities + internet (fiber $400/mo)$9,600/yr
Biohazard hauler ($90/mo) + MoCA$1,218/yr
Other recurring clinic ops~$35K/yr
Total$157,218/yr
Driver (1 per active clinic)
Base salary$45,000
No benefits load modeled$45,000/yr flat
MSO and Clinical Overhead — Annual
Central leadership + clinical ops · flat salaries (no benefits load modeled) · year-over-year totals
Clinic
Y1 Total Clinic (staff + drivers)~$664,000
Y2 Total Clinic (staff + drivers)~$1,816,000
Y3 Total Clinic (staff + drivers)~$3,425,000
MSO
Y1 MSO Operations (fully itemized)~$172,000
Y1 Total MSO (Staff + Ops)~$1,572,000
Y2 Total MSO~$2,059,000
Y3 Total MSO~$3,184,000
Tech Stack Cost — Dynamic Scaling
Scales with providers · enrolled members · revenue · clinics · staff
Provider-based ($850/provider/mo)
EHR (Athelas AIR / Athenahealth)$750/provider/mo
Commure Ambient AI documentation$100/provider/mo
Member + Revenue-based
Chronic Care IQ (CCM/APCM platform)$6/enrolled/mo
Commure RCM (revenue cycle)4% of net collections
Clinic-based
Fiber + cellular LTE failover$400/clinic/mo
Klara + Doxy.me + Samsara~$540/clinic/mo + $35/provider/mo
Bamboo PatientPing (flat portfolio)$1,500/mo flat
Compliancy Group (flat)$400/mo flat
Rippling (HR/payroll/MDM)$12/employee/mo + $35 base
Tenovi RPM in COGS, not OpEx. Device cost ($40/enrolled/mo) is deducted directly against RPM gross revenue — not double-charged in the tech stack line.
Cost Structure — Composition at Scale
Labor is the dominant cost at scale (~66% of OpEx). The critical structural advantage: CCM/APCM/RPM revenue scales with enrolled members while one care coordinator per clinic (hired on workload) keeps labor growth sublinear. Each incremental member adds ~$140/mo net revenue but only marginal additional staff cost — creating powerful operating leverage as the panel deepens.
~66%
Clinical + MSO
labor
~14%
Tech stack
(dynamic)
~16%
Clinic ops
~5%
MSO operations
(office · legal · compliance)
Stage 3 · Financial Model · Section 3.4
5-Year P&L — Annual Portfolio Summary
10-clinic portfolio · base scenario · Lease mode · 25% FFS penetration · 18-month ramp · 2.0→4.0 visits/yr. EBITDA positive Y2 ($367K) · $6.83M Y5. Net profit positive Y2 ($92K) · $5.19M Y5. CPA validation required before investor distribution.
§ 3.4Base scenario · Lease mode
25% pen · 18-mo ramp · 2.0→4.0 visits
All figures estimated
5-Year Portfolio P&L — Base Scenario
25% penetration · 18-month ramp · 2.0→4.0 visits · Lease mode · 10 clinics Y1–Y3 · all figures estimated
See financial model for live calculations
Line Item Year 1 Year 2 Year 3 Year 4 Year 5
OPERATING CONTEXT
Active clinics (EOP)36101010
Total enrolled members (EOP)1,7375,0399,10511,09711,097
REVENUE
E&M visits (2.0→4.0/yr)$227K$835K$2.00M$3.17M$3.99M
AWV bundle (IPPE/G0438/G0439 + G0444/G0442 + mod-25 E&M)$444K$1.27M$2.27M$2.72M$2.68M
APCM G0558 (QMB/Dual · ~$99/mo enrolled)$154K$716K$1.44M$2.08M$2.19M
CCM (99490/99439/99487/99489 · 82% · 55/35/10)$167K$775K$1.56M$2.25M$2.37M
APCM G0557/G0556 (standard + low acuity)$43K$200K$402K$582K$611K
TCM 99495/99496$8K$39K$78K$113K$119K
Other membership (PCM · BHI · ACP · tobacco · screenings · cognitive · H&B · procedures · vaccine admin)$241K$1.20M$2.53M$3.81M$4.17M
Subtotal Membership Revenue$1.28M$5.03M$10.28M$14.74M$16.13M
RPM gross (99453/99454/99445/99457/99458/99470)$221K$1.37M$2.99M$4.63M$5.07M
RPM device COGS (Tenovi $40/enrolled/mo)($93K)($596K)($1.31M)($2.04M)($2.25M)
Labs (i-STAT · Afinion · Sysmex) + rapid tests + vaccine products gross$199K$553K$943K$1.09M$1.03M
Lab / rapid-test / vaccine COGS($162K)($446K)($753K)($860K)($803K)
Claim denial write-off (2.5% gross)($43K)($174K)($355K)($511K)($556K)
TOTAL NET REVENUE$1.41M$5.74M$11.79M$17.05M$18.63M
OPERATING EXPENSES
MSO Staff (6 execs + lean-build staff × $125K/role)($1.40M)($1.75M)($2.75M)($3.13M)($3.13M)
MSO Operations (office · mktg · IT · legal · compliance)~($172K)~($309K)~($434K)~($534K)~($534K)
Per-clinic clinical staff + driver (reactive staffing)($664K)($1.82M)($3.43M)($4.28M)($4.63M)
Per-clinic operations (lease · supplies · malpractice · utils)~($393K)~($917K)~($1.49M)~($1.92M)~($1.92M)
Tech stack (EHR · CCM platform · RCM · connectivity · HR)($178K)($582K)($1.12M)($1.51M)($1.60M)
TOTAL OPERATING EXPENSES (before D&A)($2.81M)($5.37M)($9.22M)($11.37M)($11.80M)
EBITDA($1.40M)$367K$2.57M$5.68M$6.83M
D&A (GAAP straight-line on clinic CapEx · buildout, equipment, vehicles, tech)($73K)($159K)($253K)($261K)($257K)
Tax (21% on positive EBT)—($116K)($488K)($1.14M)($1.38M)
NET PROFIT($1.47M)$92K$1.83M$4.28M$5.19M
~Mo 2
Single-clinic EBITDA breakeven (Clinic 1, Habersham — from first patient)
~Y2
Portfolio EBITDA positive — $367K Y2 · $2.57M Y3 · $6.83M Y5 (Lease; $6.68M Own) · base scenario
~$18.6M
Y5 Net Revenue — 11,097 members · ~$140 net PMPM · $5.19M net profit (Lease) · base scenario
Stage 3 · Financial Model · Section 3.5
Capital Structure — Single $4M–$5M Raise
Single Series Seed raise at M1 — $4M (Lease) / $5M (Own) — funds the full 10-clinic buildout, MSO, and operating runway; cash stays positive all 60 months. Portfolio EBITDA turns positive in Y2. No Series A or Series B. No debt, no interest expense.
§ 3.5Single Raise: $4M Lease / $5M Own · M1
No interest
No Series A or B
Single Raise — $4,000,000
Month 1 · SAFE or Equity (convertible note optional) · full portfolio funded at close
Raise received$4.0M
CapEx deployed Y1–Y3 (clinic buildouts · equipment · vehicles)($2.0M)
Operating shortfall Y1–Y3 (loss months)($1.7M)
Minimum cash balance$1.1M (M16)
Y5 ending cash$12.9M
No Series A or Series B requiredSingle raise only
Path to Profitability
Base scenario EBITDA positive Y2 · net profit positive Y2 · strong growth trajectory
Portfolio EBITDA breakevenYear 2 ($367K; first positive month M17)
Y5 EBITDA (base scenario)~$6.83M
Net profit Y2 / Y5$92K / $5.19M
Non-dilutive pathway (CMMI)$3.36M at 400 members
Y5 Net Revenue~$18.6M
Cash Flow Milestones
Pre-launch → portfolio EBITDA breakeven (M17) · CMS pays 30–45 days after each claim
M−3 → M0
Formation
Entity · PECOS · buildout · staff hire
Raise closes · CapEx
M1–M5
Launch
Habersham M1 · Lumpkin M3 · Stephens M5 · first claims M1
$10K → $90K/mo
M6–M12
Ramp
CCM/APCM/RPM panels build
$115K → $217K/mo
M13+
Scale
White + Rabun M13 · Union M15 · clinics 7–10 M25–M29
Portfolio EBITDA+ M17
Illustrative Cap Table
SAFE converts at a priced round or liquidity event · investors hold equity in the Delaware parent only
Founders
~70%
ESOP Pool
~10%
Seed Investors (SAFE or Equity)
~20%
Non-Dilutive Pathway — CMMI Innovation Award
At 400 enrolled members · $3.36M documented CMS savings · Making Care Primary or ACCESS initiative
At 400 enrolled members with documented outcomes, SPARK Senior Health demonstrates $3.36M/year in CMS savings ($8,400 × 400). This qualifies for a CMMI Innovation Award application — converting demonstrated savings into non-dilutive expansion capital. Application window: Month 18–24 post-launch. The CMMI pathway is a structural advantage of the fixed-clinic model: documented chronic disease outcomes (HTN control, HbA1c, readmission rates) are the evidence base CMS needs. CMMI funding supplements an already self-sustaining model — the portfolio reaches EBITDA positive in Year 2 without it.
Stage 3 · Financial Model · Section 3.6
Investor ROI — Scenarios, CMS Value & Exit Paths
Three return scenarios across portfolio scale assumptions · CMS savings ROI for CMMI documentation · exit pathways and likely acquirers. The dual ROI narrative: investor returns and federal savings are the same outcome.
§ 3.6EBITDA multiple basis
Revenue multiple basis
CMMI savings model
⚠ Conservative Case
Slower Ramp
25% pen · 24-mo ramp · 10 clinics · no CMMI modeled
~2.5–2.7× MOIC by Yr 5
  • Slower enrollment: 1,298 members Y1 (vs 1,737 base) · 11,097 by Y5
  • ~$138 net PMPM (Y5 avg)
  • Portfolio EBITDA positive M21 (sustained from M26)
  • EBITDA ~$6.6M Y5 · net profit $5.0M (Lease)
  • Cash dips ~$0.1M below zero at M29 on the $4M/$5M raise — needs a small cushion or credit line
  • Exit ~$53M (Lease) / ~$63M (Own) · Investors 20% = ~$10.6M / ~$12.6M · IRR ~17–18% (~20–22% w/ QSBS)
✓ Base Case
Planned
25% pen · 18-mo ramp · 10 clinics · no CMMI modeled
~2.6–2.75× MOIC by Yr 5
  • 11,097 enrolled at Y4/Y5 maturity
  • ~$140 net PMPM (Y5 avg)
  • EBITDA ~$6.8M Y5 · net profit $5.2M (Lease)
  • Y5 revenue ~$18.6M
  • Exit ~$55M (Lease) / ~$65M (Own) · Investors 20% = ~$11M / ~$13M · IRR ~17–18% (~21–22% w/ QSBS)
  • Valuation: ~8–10× Y5 EBITDA (~3.0–3.5× revenue)
★ Growth Case
Accelerated
30% pen · 12-mo ramp · 10 clinics · no CMMI modeled
~3.7–3.9× MOIC by Yr 5
  • 13,312 enrolled at Y4/Y5 maturity · ~$141 net PMPM
  • Portfolio EBITDA positive M9 (sustained from M14)
  • Y5 revenue ~$22.5M
  • EBITDA ~$9.8M Y5 · net profit $7.5M (Lease)
  • Exit ~$79M (Lease) / ~$94M (Own) · Investors 20% = ~$15.7M / ~$18.7M · IRR ~25–27% (~30–32% w/ QSBS)
  • Valuation: same ~8–10× Y5 EBITDA as base · CMMI award would be upside
💰 CMS / CMMI ROI
Federal Value
CMS savings at scale vs. total revenue paid to Spark
4–6× CMS saves per $1 paid
  • 400 members → $3.36M savings/yr
  • Spark billed CMS ~$1.4M → +$1.9M net
  • 11,097 members → ~$93.2M savings/yr
  • Spark billed ~$18.6M (Y5) → +$74.6M net
  • 10-yr cumulative: ~$746M federal savings net
  • CMMI case: strongest in rural primary care
Exit Pathways — Year 5–7
Valuation basis · most likely acquirers
Strategic Acquisition
NGHS, Wellstar, Piedmont, Navicent, or regional ACO acquires for rural reach + CMS attribution (11,097 members) + HPSA-county compliance moat + CMMI track record.
$55–65M · ~8–10× EBITDA ($6.7–6.8M Y5 base)
CMMI Scale Contract
CMMI Innovation Award converts to multi-year performance contract at 400+ members. Expansion capital becomes federal funding. Non-dilutive and non-exit — but changes the growth trajectory permanently.
Non-dilutive · $2–10M/yr · Month 18–24
Private Equity Roll-Up
PE aggregator of rural primary care fixed-clinic models. Requires reproducible operations playbook and multi-county presence demonstrating the model's scalability to 49 other states.
~$27–34M · 4–5× EBITDA ($6.7–6.8M Y5) · ~1.5× revenue ($18.6M Y5)
The Dual ROI Narrative
Why investor returns and CMS savings are the same story
For investors: A scalable recurring revenue model in a structurally underserved market. CCM/APCM/RPM convert one-time visits into monthly subscription-like income. ~$140 net PMPM steady state (Y5). Base scenario reaches EBITDA positive Y2 ($367K), net profit positive Y2 ($92K), and $6.83M EBITDA / $5.19M net profit by Y5 (Lease; $6.68M / $5.01M Own). Exit ~$55M (Lease) / ~$65M (Own) at ~8–10× Y5 EBITDA.
For CMS: Every dollar paid to SPARK Senior Health produces $4–6 in downstream savings through reduced ER visits, hospitalizations, and unmanaged chronic disease. At 11,097 members (full portfolio maturity), net federal benefit is ~$74.6M/yr ($93.2M savings − $18.6M billed). ~$746M over 10 years. The strongest CMMI innovation argument in rural primary care.
Thesis: The fixed clinic solves access. Transportation removes the last barrier. CCM/APCM/RPM solves chronic disease management. The CMS savings solve capital. Investors and the federal government are co-investors in the same outcome — each paying for the same activity, each receiving their respective return.
Stage 3 · Financial Model · Summary
Stage 3 Key Findings
Financial model established across reimbursement schedule, member ramp, expense structure, 5-year P&L, capital structure, and investor return scenarios. One open item requires resolution before investor distribution: CPA validation of the financial model. (Billing structure is confirmed: NPs bill under their own NPI at 85%.)
∑Stage 3 Summary
6 sections complete
~$140
Net PMPM (Y5 average) · base scenario
~Mo 2
Single-clinic EBITDA breakeven · Clinic 1 from first patient
$4M–$5M
Single raise · SAFE or Equity · Month 1 · $4M Lease / $5M Own
~Y2
Portfolio EBITDA positive · $367K Y2 · $6.83M Y5 (Lease)
~2.6–2.75×
Base case investor MOIC · $55–65M exit · IRR ~17–18% (~21–22% w/ QSBS) · Y5 EBITDA $6.8M · net profit $5.2M (Lease)
~$93M
Annual CMS savings at full portfolio maturity (11,097 members · $93.2M gross)
Stage 3 Chapter Recap
Six sections · what was established
3.1Reimbursement schedule — 2026 MPFS rates at NP 85%. APCM G0558 ~$99/mo, CCM 99490 ~$56/mo, RPM net ~$50/enrolled/mo after $40 COGS. Net PMPM ~$140 (Y5, bottom-up). Member tiers: Standard FFS = Tier 1, SLMB = bill same, QMB = write-off visit/Dx only (CCM/RPM unaffected), D-SNP = excluded Y1–2.
3.2Member ramp — 18-month per-clinic ramp clock (independent), panel = FFS pool × 25% (no cap). 1,737 enrolled Y1, 5,039 Y2, 9,105 Y3, 11,097 Y4/Y5. Clinic-level EBITDA positive ~Month 2 at Habersham; all 3 Y1 clinics positive by their 8th month open. Per-clinic terminal revenue ~$165K/mo (Habersham, M18).
3.3Expense structure — Per-clinic ops $157,218/yr (Lease). Driver $45K/yr (no benefits load). MSO (staff + ops) Y1 $1.572M → Y2 $2.059M → Y3 $3.184M. Tech stack scales dynamically. Labor ~66% of OpEx at scale.
3.45-year P&L (Lease) — Y1 revenue $1.41M, EBITDA ($1.40M), net ($1.47M); Y2 $5.74M, EBITDA $367K, net $92K; Y3 $11.79M, EBITDA $2.57M, net $1.83M; Y4 $17.05M, EBITDA $5.68M, net $4.28M; Y5 $18.63M, EBITDA $6.83M, net $5.19M. EBITDA positive from Y2.
3.5Capital structure — Single Series Seed raise: SAFE or Equity, convertible note optional (M1) — $4M (Lease) / $5M (Own). No Series A or Series B, no debt, no interest. Illustrative cap table: Founders 70%, ESOP 10%, Series Seed investors 20%. CMMI non-dilutive pathway at 400 members. The raise covers $2.0M CapEx and the Y1 loss ($1.47M); cash stays ≥$1.1M (Lease) all 60 months.
3.6Investor ROI — MOIC: base ~2.6–2.75× ($55M Lease / $65M Own exit), conservative ~2.5–2.7× (24-mo ramp), growth ~3.7–3.9× (30% pen, 12-mo ramp). CMS ROI $4–6 saved per $1 billed; ~$93M gross savings/yr at full portfolio. Three exit pathways: strategic acquisition $55–65M, CMMI scale contract, PE roll-up ~$27–34M. Base case: $6.8M Y5 EBITDA → $55–65M exit.
Next → Stage 4
Legal, Compliance & Structure
Corporate structure · MSO/PC design · CMS enrollment · Georgia compliance · shareholder documents · OIG audit program