Phase 1 Launch Blueprint for ClearHealth Basic outlines the entity structure, operational model, and early-year financial plan for a portable, member-funded health coverage system.
🏗️ 1. Entity & Structural Setup
| Layer | Entity | Purpose | Notes |
|---|---|---|---|
| Holding Co. | ClearHealth LLC | Owns brand, technology, and IP | Formed as a Washington or Delaware LLC |
| Health Fund | ClearHealth Basic Member Pool Trust | Holds and disburses member contributions | Legally distinct trust or custodial account for claims funds |
| Administrator | ClearHealth Admin Services LLC | Licensed TPA / service provider | Handles enrollment, claims, eligibility, and member support |
| Reinsurer | Symetra / QBE / HM Insurance | Protects the program from unusually large claims | Per-member or aggregate stop-loss contract |
| HSA Custodian | Lively / HealthEquity / Fidelity | Manages member HSAs | Members contribute directly; ClearHealth never holds HSA funds |
| Bank & Trust Partner | Cross River / Piermont / Blue Ridge Bank | Custody and claim-float management | Provides fiduciary segregation of member funds |
💡 You control ClearHealth LLC and Admin Services; the member trust holds pooled funds for transparency and legal separation.
⚙️ 2. Operational Flow
Member → enrolls → pays monthly contribution
↓
Member and/or employer funds member-owned HSA
↓
Funds split into:
- Member Claim Fund
- Program stop-loss / reinsurance
- Administration, technology, compliance, and reserves
↓
Member uses telehealth / Cost Plus / direct-care providers
↓
If claim < $50 k → paid from Claim Fund
If claim ≥ $50 k → Stop-Loss reimburses ClearHealth Fund
↓
Year-end surplus → retained for reserves or rebated to members
💰 3. Financial Model (Year 1 Projection)
Assumptions
- 1 000 members (average risk)
- $450 per member per month individual contribution target
- $300 per member per month expected claims fund
- $75 per member per month program stop-loss / reinsurance budget
- Reserve margin built into the contribution rather than treated as an afterthought
| Category | Per Member per Month | Annual Total |
|---|---|---|
| Member Contributions | $450 × 1 000 × 12 = $5.4 M | $5 400 000 |
| Expected Claims Fund | $300 × 1 000 × 12 = $3.6 M | $3 600 000 |
| Program Stop-Loss / Reinsurance | $75 × 1 000 × 12 = $900 k | $900 000 |
| Admin, TPA, Payments, Support | $40 × 1 000 × 12 = $480 k | $480 000 |
| Tech, Pharmacy Integration, Compliance | $15 × 1 000 × 12 = $180 k | $180 000 |
| Reserve / Operating Margin | $20 × 1 000 × 12 = $240 k | $240 000 |
➡ Projected Year-1 Reserve / Operating Margin: ≈ $240 k — used for operating cushion, growth, compliance, or member-aligned surplus policy. ➡ If claims run below expected, surplus can be retained for reserves or rebated under the program rules.
🧾 4. Capital & Regulatory Requirements
| Category | Requirement | Est. Cost |
|---|---|---|
| Initial Capital | Reserve ≈ 2 months of claims + operations | $900 k – $1.1 M |
| Stop-Loss Premium Deposit | One month upfront | $75 – 100 k |
| Legal & Compliance | Trust docs, TPA filing, contracts, member agreements | $50 – 100 k |
| Tech MVP Build | Member portal + claims ledger API | $100 – 150 k |
➡ Target capital to launch: ≈ $1.1 – 1.4 M (including operational float).
⚖️ 5. Regulatory Path
Step 1 – Operate as a TPA (Non-insurance)
- Register ClearHealth Admin Services LLC as a Third-Party Administrator where required.
- Contract with stop-loss carriers and HSA custodians.
- Handle claims administration and member support for the ClearHealth Fund.
- No insurance license required since the fund is member-owned and fully disclosed.
Step 2 – Member-Funded Health Pool (Non-ERISA)
- Each member joins ClearHealth Basic and contributes monthly to the shared fund.
- Funds are held in trust and used solely for eligible medical claims.
- Stop-loss coverage protects the pool against catastrophic loss.
- Members receive transparent monthly and annual statements of fund usage and reserves.
- Because coverage is individual and portable, the model is designed to avoid employer-owned group-plan dependency.
- Employers may contribute to member HSAs or provide defined contribution support, but the member keeps the plan relationship.
Step 3 – Captive or Health Co-op Formation (After Year 1–2)
- Once claims data and membership stabilize, evaluate established captive domiciles and form a regulated captive where the regulatory fit, capital requirements, healthcare-risk experience, and reinsurance access are strongest.
- Captive assumes stop-loss risk and manages investment float.
- Gains long-term control of reinsurance pricing and risk capital.
🌱 6. Growth Model
| Phase | Members | Revenue | Notes |
|---|---|---|---|
| Pilot (6 mo) | 100 – 250 | $100 k – $300 k | Demonstrate loss ratio < 85 % |
| Year 1 | 1 000 | $5.4 M | Add reinsurance partner |
| Year 2 | 3 000 | $16.2 M | Introduce DPC & wellness add-ons |
| Year 3 + | 10 000 + | $54 M + | Captive conversion + multi-state filings |
🔐 7. Key Partnerships
| Function | Partner Type | Example Providers |
|---|---|---|
| HSA Custodian | Bank / Fintech API | Lively API, Fidelity HSA |
| Reinsurance | Stop-loss carrier | Symetra, QBE, HM |
| TPA Platform | Claims + eligibility | Marpai, Gusto Benefits Infra |
| Pharmacy Pricing | Transparent drug sourcing | Cost Plus Drugs API |
| Telehealth | Virtual care platform | Wheel, SteadyMD |
| Payments | ACH + ledger infrastructure | Unit, Treasury Prime, Stripe Treasury |
🚀 8. Next Steps for Launch
- Form ClearHealth LLC and ClearHealth Admin Services LLC.
- Engage an actuarial partner to model expected claims and stop-loss thresholds.
- Secure reinsurer and bank partner for trust and premium flows.
- Develop MVP tech stack – portal, ledger, Cost Plus API integration.
- Launch pilot cohort (100 – 250 members) and collect claims data.
- Analyze fund performance and optimize pricing.
- Evaluate captive formation after proof of concept.
Summary
ClearHealth Basic is a transparent, member-funded health coverage platform that pairs direct-care pricing with collective risk protection and HSA compatibility. Each member owns their participation directly; employers can help fund the member's HSA or contribution without owning the full insurance relationship. ClearHealth Admin Services manages operations and claims on behalf of the membership, while ClearHealth LLC maintains technology, contracts, and reinsurance relationships.