Health Plan Executive Demo

Simulated Medicare Advantage plan · 100,000 members · Board-ready intelligence brief

Medicare AdvantagePlan Year 2026Live Simulation

Total Members

100,000

+2.4% YoYContinuously enrolled

Total Medical Spend

$1370M

-3.1% vs planAnnualized

PMPM

$1142

-$34 vs PYRisk-adjusted

Specialty Pharmacy

$184M

+11.4% YoY13% of spend

Executive Opportunity Score

0–100 composite

High Actionability

Clinical

Financial

Quality

Estimated Annual Savings Opportunity

Annualized

Total Opportunity

$161M

All levers

Realized Savings YTD

$42.8M

27% captured

Projected Savings

$118M

Next 12 mo

Risk Adj. (RAF) Opp.

$31.2M

HCC recapture

HEDIS Gap Opp.

$14.6M

Stars uplift

Cost & Utilization Drivers

Top 1% High-Cost Claimants

1,000

28% of spend$384M concentrated

Members Driving 50% of Spend

4,800

4.8% of pop.Care mgmt targets

Avoidable Admissions

3,120

-12% vs PY$38.4M opp.

Avoidable ER Utilization

18,400

-8.6% vs PY$22.6M opp.

Readmission Risk (30-day)

14.6%

-1.2 ptsTarget 11%

Dialysis Population

1,180

$9,840 PMPMESRD program

Oncology Population

2,640

$6,120 PMPMPathway compliance

CHF · COPD · Diabetes

30,420

30.4% prev.Chronic registries

Spend Concentration Curve

% of total medical spend

The top 5% of members drive 42% of total medical spend — care management ROI concentrates here.

MLR · ER · Readmissions Trend

Trailing 8 months

Disease Registries

Stratified by PMPM intensity

Dialysis

1,180

members in registry

PMPM$9,840

Oncology

2,640

members in registry

PMPM$6,120

CHF

6,420

members in registry

PMPM$2,480

COPD

5,640

members in registry

PMPM$1,980

Diabetes

18,360

members in registry

PMPM$1,240

Top 1% High-Cost Claimants — Representative Sample

Annualized cost ($K)

Member	ID	Cohort	Annual Cost	Intervention
M. Alvarez	MBR-48201	Dialysis ESRD	$612K	Complex care mgmt · pharmacy review
R. Chen	MBR-30911	Oncology — Multi-line	$488K	Complex care mgmt · pharmacy review
T. Johnson	MBR-72104	Post-transplant	$372K	Complex care mgmt · pharmacy review
P. Singh	MBR-19883	MS biologic	$298K	Complex care mgmt · pharmacy review
L. Okafor	MBR-55620	Crohn's biologic	$264K	Complex care mgmt · pharmacy review
K. Müller	MBR-66712	Hemophilia A	$241K	Complex care mgmt · pharmacy review
A. Rivera	MBR-22091	CHF + COPD	$218K	Complex care mgmt · pharmacy review
D. Ferreira	MBR-83310	Sepsis · readmits	$196K	Complex care mgmt · pharmacy review

Board of Directors Summary

CEO Lens

Plan is tracking 3.1% favorable to budget with $161M in addressable opportunity — equivalent to an 11.8% reduction in total medical spend.

CFO Lens

$42.8M already realized YTD. Projected $118M over next 12 months drives MLR from 88.2 → 83.4% and lifts MA bid margin by ~210 bps.

CMO Lens

4,800 members concentrate 50% of spend. RAFIQ has triaged 1,000 top-1% claimants into care pathways — readmissions trending toward 11% target.

CFO Board Scenario Planner

Executive Financial Scenario Model · Adjust performance levers · Recalculates in real time

Medicare Advantage · Medicaid

Performance Levers

Drag to model

Admissions Reduction

25%

0%of avoidable admits100%

ER Reduction

20%

0%of avoidable ER100%

Specialty Pharmacy Savings

15%

0%site-of-care / biosim100%

HCC Recapture Rate

30%

0%of suspected gaps100%

Care Gap Closure (HEDIS/Stars)

40%

0%quality bonus uplift100%

Total Savings

$55.0M

annualized4.0% of spend

PMPM Impact

-$25

→ $1117from baseline

MLR Impact

84.9%

-3.3 ptsfrom 88.2%

EBITDA Impact

$36.5M

net of program-$18.5M invest

ROI

2.0x

return multipleEBITDA / program $

Savings Waterfall

By lever ($M)

MLR Trajectory

Current · Scenario · Target

CFO Narrative

At the modeled performance, RAFIQ delivers $55.0M in combined cost-out and risk-adjusted revenue uplift, compressing MLR by 3.3 points to 84.9% and producing $36.5M EBITDA on a $18.5M program investment — a 2.0x ROI.