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Table of Contents
Why this and why now
The mandate with the abandoned supply
What the business actually does
Sizing it without lying
Who pays and why they pay
The preseed: five million dollars and twelve months
Weeks one through eight
Months three through six
Months seven through twelve
The milestones that unlock the mega seed
What the twenty five million buys
Where it breaks
Abstract
Starting January 1, 2027, all states that have adopted the ACA Medicaid expansion (or equivalent expansion coverage) must condition Medicaid coverage for applicable expansion adults on 80 hours per month of qualifying community engagement activity or a documented exemption, with some states, including Nebraska, authorized to implement earlier at state option.
The interim final rule interprets the medical frailty exemption as a clinical determination tied to functional impairment rather than a simple diagnosis code lookup, and no organization in the ecosystem is currently staffed to produce those determinations at the required scale.
The business is a tech enabled clinical exemption and reinstatement service sold on contingency to FQHCs, community behavioral health providers, hospitals, and managed care plans, structurally modeled on the SSDI advocacy and hospital eligibility vendor industries.
The addressable pool is roughly 18.5 million subject enrollees, several million of whom have qualifying conditions, with a per member value to the payer of roughly $6,000 to $8,000 a year in capitation and a per member value to providers measured in avoided bad debt.
A $5 million preseed should buy three early state beachheads, twenty thousand completed determinations, a measured exemption rate, a reinstatement win rate, and signed contingency contracts with a dozen provider organizations and one plan before the national go live date.
The $25 million seed funds the expansion to all applicable expansion states in the first half of 2027, when the disenrollment wave actually hits and every plan and health system finance chief is suddenly reading the rule.
