Medicare Advantage
🛡️ Public data only — no PHI permitted on this instance.
Medicare Advantage Contract Analyzer
Bid/benchmark · RAF optimization · Stars · MLR · V28 transition · supplementals — 1,410 corpus deals
Enrollment
85,000
Bench PMPM
$1,824
Bid PMPM
$1,741
Star (wtd)
3.96
MLR
85.8%
Revenue
$1,833M
Margin
$57M
(3.1%)
V28 Net
$-89.2M
Corpus Deals
1,410
Revenue vs Margin by MA Plan
MA Plan Portfolio — Benchmark, Bid, Star, MLR, Margin
| Plan | Type | Enrollees | RAF | Benchmark PMPM | Bid PMPM | Rebate | Star | Bonus | MLR | Margin PMPM | Revenue ($M) | Margin ($M) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Platform HMO Gold | HMO | 35,700 | 1.092 | $1,146.60 | $1,100.74 | $29.81 | 4.0 | 5.0% | 84.5% | $84.90 | $484.97 | $36.37 |
| Platform PPO Silver | PPO | 19,550 | 1.146 | $1,203.30 | $1,143.13 | $39.11 | 3.5 | 3.5% | 85.5% | $65.10 | $277.68 | $15.27 |
| Platform DSNP | D-SNP | 15,300 | 2.534 | $2,660.70 | $2,580.88 | $51.88 | 4.5 | 5.0% | 86.8% | $57.98 | $483.85 | $10.64 |
| Platform CSNP Diabetic | C-SNP | 6,800 | 3.207 | $3,367.35 | $3,131.64 | $153.21 | 4.0 | 5.0% | 88.2% | $-6.59 | $268.67 | $-0.54 |
| Platform ISNP LTC | I-SNP | 4,250 | 5.251 | $5,513.55 | $5,237.87 | $179.19 | 4.5 | 5.0% | 89.5% | $-135.65 | $276.73 | $-6.92 |
| Platform HMO Basic | HMO | 3,400 | 0.990 | $1,039.50 | $966.74 | $47.30 | 3.0 | 0.0% | 86.2% | $58.81 | $41.37 | $2.40 |
RAF Optimization — HCC Capture Opportunities
| HCC Category | Prevalence | RAF Contrib | Current Capture | Target Capture | Gap | Incremental Rev ($M) |
|---|---|---|---|---|---|---|
| Diabetes (HCC 17-19) | 32.0% | 0.318 | 64.0% | 76.0% | +12.0pp | $1.37 |
| CHF / Heart Failure (HCC 85) | 14.0% | 0.368 | 61.0% | 73.0% | +12.0pp | $0.69 |
| COPD / Asthma (HCC 111-112) | 18.0% | 0.335 | 68.0% | 80.0% | +12.0pp | $0.81 |
| Chronic Kidney Disease 4-5 (HCC 136-138) | 8.0% | 0.428 | 79.0% | 91.0% | +12.0pp | $0.46 |
| Major Depression (HCC 58-59) | 22.0% | 0.309 | 64.0% | 76.0% | +12.0pp | $0.92 |
| Vascular Disease (HCC 108) | 16.0% | 0.288 | 76.0% | 88.0% | +12.0pp | $0.62 |
| Morbid Obesity (HCC 22) | 12.0% | 0.250 | 61.0% | 73.0% | +12.0pp | $0.40 |
| Dementia / Alzheimer's (HCC 51-52) | 9.0% | 0.395 | 56.0% | 68.0% | +12.0pp | $0.48 |
| Cancer - Active (HCC 8-14) | 7.0% | 0.625 | 63.0% | 75.0% | +12.0pp | $0.59 |
| Protein-Calorie Malnutrition (HCC 21) | 4.0% | 0.455 | 83.0% | 95.0% | +12.0pp | $0.25 |
Star Rating Roadmap — Quality Bonus Unlock
| Measure Domain | Current | Target | Weight | Bonus Revenue ($M) | Priority |
|---|---|---|---|---|---|
| HEDIS Clinical Measures | 4.0 | 4.5 | 40% | $0.43 | high |
| CAHPS Patient Experience | 3.5 | 4.0 | 25% | $0.27 | high |
| HOS Health Outcomes | 4.0 | 4.5 | 15% | $0.16 | high |
| Complaints & Disenrollment | 3.0 | 4.0 | 10% | $0.21 | critical |
| Part D Drug Safety | 4.0 | 4.5 | 5% | $0.05 | high |
| Appeals / Timely Decisions | 3.5 | 4.0 | 5% | $0.05 | high |
V28 Risk Model Transition — Revenue Headwind
| Plan Segment | V24 RAF | V28 RAF | Delta | Revenue Impact ($M) | Full Blend Year |
|---|---|---|---|---|---|
| Platform HMO Gold | 1.092 | 1.051 | -0.041 | $-18.44 | 2026 |
| Platform PPO Silver | 1.146 | 1.098 | -0.048 | $-11.82 | 2026 |
| Platform DSNP | 2.534 | 2.395 | -0.139 | $-26.80 | 2026 |
| Platform CSNP Diabetic | 3.207 | 3.031 | -0.176 | $-15.08 | 2026 |
| Platform ISNP LTC | 5.251 | 4.962 | -0.289 | $-15.48 | 2026 |
| Platform HMO Basic | 0.990 | 0.952 | -0.038 | $-1.63 | 2026 |
MLR Waterfall — Medical Cost Components vs Target
| Component | PMPM Cost | % Premium | YTD Actual | Target | Variance |
|---|---|---|---|---|---|
| Inpatient Facility | $165.00 | 16.50% | 16.80% | 16.00% | +0.80pp |
| Outpatient Facility | $128.00 | 12.80% | 13.00% | 12.50% | +0.50pp |
| Professional / MD | $185.00 | 18.50% | 18.90% | 18.00% | +0.90pp |
| Pharmacy (Part D) | $148.00 | 14.80% | 15.20% | 14.50% | +0.70pp |
| Skilled Nursing | $62.00 | 6.20% | 5.80% | 6.00% | -0.20pp |
| Home Health / DME | $42.00 | 4.20% | 4.40% | 4.00% | +0.40pp |
| Administrative | $85.00 | 8.50% | 8.20% | 9.00% | -0.80pp |
| Supplemental Benefits | $48.00 | 4.80% | 5.10% | 4.50% | +0.60pp |
Supplemental Benefit Portfolio — Utilization & ROI
| Benefit | Utilization | Cost PMPM | Enrollment Impact | ROI Score |
|---|---|---|---|---|
| Dental Preventive | 62.0% | $18.50 | high — D-SNP driver | 4.2 |
| Vision Exam + Eyewear | 38.0% | $9.20 | medium | 3.8 |
| OTC Card ($100/qtr) | 78.0% | $28.00 | very high | 4.7 |
| Flex Card Grocery | 55.0% | $42.50 | high — SNP only | 3.9 |
| Hearing Aids | 22.0% | $12.80 | medium | 3.2 |
| Transportation (non-emer) | 18.0% | $8.50 | low | 2.4 |
| SilverSneakers Fitness | 35.0% | $4.20 | medium | 3.6 |
| In-Home Support | 8.0% | $35.00 | high — I-SNP | 3.8 |
MA Thesis: 85,000 MA lives at $1,741 bid PMPM.
$1,833M revenue, $57M margin (3.1%), MLR 85.8%, weighted star 3.96.
V28 phase-in erodes $89.2M revenue by 2026. Offset via RAF capture ($6.6M incremental)
and star uplift to 4.5 ($1.2M bonus). D-SNP/I-SNP segments carry highest margin per life
but face steepest V28 headwind. Supplemental benefit dollar should follow ROI ranking — OTC and Flex cards lead.