Pricing, business model, and regulatory path — focused on an HSA-compatible, transparent, low-overhead plan like ClearHealth Basic.

💵 1. Pricing: What You Could Realistically Offer It For

These estimates are based on realistic assumptions for a transparent, member-funded health plan that uses reference-based pricing and stop-loss protection.

Core assumptions

• Plan type: HSA-compatible high-deductible plan
• Deductible: $2,000 / $4,000 family
• Reimbursement basis: approximately 120% of Medicare (reference-based)
• Stop-loss attachment: $50,000 per individual
• Target market: healthy to average-risk individuals (freelancers, LLC owners, and families)

Estimated Total Monthly Contribution

This equates to roughly $3,900 – $4,800 per year for an individual, competitive with ACA bronze HDHPs but with clear pricing, Cost Plus prescriptions, and no network restrictions.

🏦 2. Business Model Options

ClearHealth can scale through three structural approaches, each with its own timeline and regulatory considerations.

Option A — Partner Model (MGA / MGU Hybrid)

• Partner with a licensed carrier that already offers HSA-eligible HDHP coverage.
• ClearHealth provides the transparent pricing layer and member-facing platform.
• Operate as a Managing General Agent (MGA) or Managing General Underwriter (MGU).
• Revenue: per-member admin fee (around $25 PMPM) and shared margin with the carrier.

Advantages: fastest route to market, leverages carrier licensing and compliance. Limitations: less control over underwriting, claims, and fund logic.

Option B — Member-Funded Health Pool (Current Model)

• Members contribute monthly to the ClearHealth Fund, held in a segregated trust.
• ClearHealth Admin Services LLC acts as the licensed TPA and administrator.
• Stop-loss coverage protects the fund against high-cost claims.
• Any year-end surplus can be retained as reserves or rebated to members.

Advantages: full control and transparency; non-ERISA, individual coverage; portable and scalable. Limitations: requires strong trust, compliance, and reinsurance partnerships.

Option C — Captive or Mutual Conversion (Phase 2 or 3)

• After scaling to several thousand members, form a regulated captive insurer.
• The captive assumes stop-loss risk and manages reserves and investments.
• Operates similarly to a member-owned mutual association.

Advantages: long-term control over risk and pricing, strong alignment with members. Limitations: requires state licensing and $250k–$500k in capitalization.

How ClearHealth Generates Revenue

⚖️ 3. Regulatory Path

Phase 1 — Operate as a TPA / Tech Platform

• Register ClearHealth Admin Services LLC as a Third-Party Administrator in Washington or Delaware.
• Contract with stop-loss carriers, banks, and HSA custodians.
• Manage claims, member eligibility, and payment flow.
• No insurance license required; ClearHealth operates as a tech-enabled administrator.

Phase 2 — Member-Funded Health Pool

• Launch ClearHealth Basic for individuals and small LLCs.
• Maintain funds in trust for transparency and member protection.
• Use stop-loss coverage to guard against catastrophic losses.
• Remains outside ERISA and state group plan regulations.

Phase 3 — Captive Formation (After Scale)

• Apply for a captive license in Vermont, Delaware, or Hawaii.
• The captive reinsures the ClearHealth Fund and manages surplus reserves.
• Optional step toward becoming a regulated mutual insurer.

📊 4. Suggested Execution Timeline

🌐 5. Positioning Summary

Tagline:

“Transparent, HSA-friendly health coverage with honest prices and no networks.”

Revenue mix at scale:

• 80% member contributions and claims flow
• 10% reinsurance commissions
• 10% data and wellness insights

Target gross margin: 8–12% after stop-loss

Key Differentiators

• Transparent reference-based pricing
• Integrated Cost Plus prescription access
• Real-time HSA reimbursement workflows
• Low administrative overhead through automation
• Portable, member-owned coverage (non-ERISA)
• Path to captive formation for long-term stability
• Competitive cost vs. ACA HDHPs
• Scalable nationwide membership
• Alignment of incentives — healthier members, lower costs
• Data-driven, ethical, and transparent operations
• Partnerships with direct-care providers and fintech platforms
• ClearHealth positioned as a trusted, modern alternative to traditional insurance

Summary: ClearHealth begins as a transparent, member-funded health coverage pool, evolves into a technology-driven cooperative structure with stop-loss protection, and matures into a captive framework that gives members ownership and control of their healthcare funding — all without entering the employer-sponsored or ERISA-regulated ecosystem.