Hello, and welcome to the CareMax, Inc. Second Quarter 2023 Financial Results and Conference Call. [Operator Instructions]. I will now turn the conference over to Samantha Swerdlin, Vice President of Investor Relations. Please go ahead..

Thank you, and good morning, everyone. Welcome to CareMax's Second Quarter 2023 Earnings Call. I'm Samantha Swerdlin, Vice President of Investor Relations, and I'm joined this morning by Carlos de Solo, our Chief Executive Officer; and Kevin Wirges, our Chief Financial Officer.

During this call, we will be discussing certain forward-looking information. These forward-looking statements are based on assumptions and assessments made by CareMax's management in light of their experience and assessment of historical trends, current conditions, expected future developments and other factors they believe to be appropriate.

Any forward-looking statements made during the call are made as of today, and CareMax undertakes no duty to update or revise such statements. Whether as a result of new information, future events or otherwise.

Important factors that could cause actual results, developments and business decisions to differ materially from the forward-looking statements are described in the company's filings with the SEC including the section entitled Risk Factors. In today's remarks by management, we will be discussing certain non-GAAP financial metrics.

A reconciliation of these non-GAAP financial metrics the most comparable GAAP measures can be found in this morning's earnings press release. With that, I'd now like to turn the call over to Carlos..

Thank you, Samantha. Good morning, everyone, and thank you for joining our call. Today, I plan to review our second quarter performance, provide an update on the progress we are making executing our growth strategy and discuss our outlook for the remainder of the year.

Before I review our second quarter results, I want to highlight some of our significant milestones and accomplishments this year. In Q2, we achieved a major milestone by surpassing 100,000 Medicare Advantage members on the CareMax platform.

Our platform is now managing over 270,000 value-based care lives spanning a diverse set of health plans, government programs and geographies. It is remarkable to consider that just 2 years ago, we had a little over 20,000 Medicare Advantage members, all concentrated in Florida.

This progress is a testament to the effectiveness of our growth strategy and the rising demand for our value-based care offerings. Furthermore, we have more than doubled our active MA Value-Based Care contracts, since completing the Steward acquisition and are currently managing over 80 contracts with more than 25 national and local health plans.

We believe the breadth of our membership and the ongoing investments in our platform will position us to deliver on our long-term growth targets. Moving on to our second quarter performance. We reported total revenue $224 million and adjusted EBITDA of $7 million, which was impacted unfavorably by approximately of prior year development.

This was attributed to data migration issues at a single Medicaid health plan that was acquired by a national payer. We have a well-established relationship with the payer and have engaged in discussions regarding the importance of the availability of data.

We also amended our agreement with the payer to reflect better economics, which we believe should translate to improved the medical margin going forward. Kevin will provide more detail on this later. Medical expense ratio was 84.6% for the second quarter, bringing our first half MER to 80.4%.

It's important to recognize that we believe that absent prior year developments, MSO mix and enhanced supplemental benefits, the MER of our centers in the first half of the year would have been approximately in line with our historical performance. We believe that our revenue and membership growth demonstrate positive momentum for our platform.

Putting us on track to exceed our original revenue guidance range for 2023. At the same time, our underlying profitability year-to-date gives us confidence in achieving our adjusted EBITDA guidance for 2023 despite prior year developments in the first half.

As of quarter end, we had approximately $55 million in cash and $60 million of undrawn capacity on our delayed draw term loans. We continue to believe that this provides us with sufficient capital to bridge us to sustainable free cash flow by Q4 of 2024. Now turning to some additional highlights from the quarter.

We are pleased to report that our Medicare Inpatient cost trends have outperformed our internal expectations. Our rates of inpatient admissions and cost per admissions have been trending down so far this year, a testament to the effectiveness of our integrated Care model in managing patient outcomes.

We observed a brief increase in MA outpatient surgical utilization during this quarter. However, this appears to have normalized and utilization trends are now back in line with expectations. Moreover, we have also successfully reduced our external specialty leakage by 10% this year compared to last year.

This achievement is the direct result of our efforts to manage more specialist volume in-house, effectively reducing unnecessary utilization and mitigating cost increases in outpatient surgical costs with lower external specialty fee-for-service volume.

We believe that our ability to effectively manage inpatient utilization and efficiently control specialty costs through our high-touch integrated care model positions us well to excel in varying market conditions and continue delivering strong results.

On the operational side, we continue to deliver solid performance at our centers and remain focused on ensuring our members have access to consistent high-quality care. Year-to-date, we have seen 85% of our Medicare members.

We are particularly proud of our de novo expansion beyond our core South Florida market and now have over 4,000 Medicare Advantage patients across our 17 centers in New York, Memphis, Houston and the space close to Florida.

We have further expanded our contracted specialty services in New York, adding optometry to existing services like dental cardiology and podiatry. We believe that these offerings will be highly attractive to seniors and will serve as a key point of differentiation from others in the market.

Additionally, we have expanded into behavioral health services in Memphis. Further enhancing the comprehensive care we provide to our members. Now turning to our MSO expansion. We believe the integration of Steward is progressing well, and we are confident in achieving our membership growth targets that were discussed at our Investor Day in March.

We have more than doubled our active Medicare value-based care contract, since completing the acquisition with more contracts expected to become active over the next year.

We believe this expanded base enables us to execute our strategy of transitioning fee-for-service panels to value-based care and also provides the opportunity to add additional members through our organic growth channels.

To promote seamless operations and high-quality care, we are actively supporting our providers with risk adjustment and quality resources, which covers over 70% of our patients. Additionally, we are diligently preparing over 100 practices across the portfolio for AEP with sales and broker support.

In our commitment to improve patient outcomes, we recently launched a Medicare Advantage Clinical Liaison Program. Through this initiative, we're collaborating with Medicare Advantage payers to facilitate coordinated care between payers, providers and patients.

This program aims to further elevate the level of care our members receive, while promoting a greater partnership among all stakeholders involved in their healthcare journey.

As I've shared with you on previous conference calls, we have been diligently working on enhancing our data infrastructure capabilities and implementing CareOptimize in the most efficient way.

We recognize the potential in harnessing the vast amount of data we receive daily to drive significant improvements in financial, clinical and operational aspects of our organization, especially given the rapid growth we've been experiencing.

While our new infrastructure continues to evolve, we have already implemented systems and processes that utilize sophisticated data ingestion, cleansing and validation methods. This is designed to provide a high level of data accuracy to drive insights and operational efficiencies, ultimately leading to better results for our patients.

To wrap up, we are very encouraged by our underlying performance in the first half of the year and the progress we are making integrating our MSO providers into the CareMax platform.

Our core centers and underlying MER are performing well and we believe we have a line of sight into achieving our near-term and long-term membership and financial targets.

Since founding CareMax and growing it to where we are today, we remain dedicated to creating a more sustainable healthcare delivery system through disciplined growth in a capital-efficient manner. We believe our unique and deliberate approach to growth will ultimately deliver the best returns for our shareholders.

With that, I'll now turn things over to Kevin to provide more details on our financial performance in the second quarter..

Thanks, Carlos, and good morning. Despite the prior year development and our second quarter results, we continue to feel good about our progress in building a nationally skilled platform to invent high-quality care for hundreds of thousands of seniors.

Since the Steward acquisition, we've added over 40 MSO risk contracts and continue to have an active pipeline of payers and providers eager to align themselves with CareMax.

These contracts have begun contributing meaningful capitated cash flows for us to invest in our medical management capabilities, and we believe our MSO-MA contracts in aggregate are accretive to medical margin. Before I get into the second quarter results, let me address a couple of items.

First, we've adopted a change in our reporting of adjusted EBITDA to no longer add back certain compensation costs previously included within business combination integration cost adjustments. Given effect to this change, our 2022 adjusted EBITDA would have been approximately $2.9 million lower than previously reported.

And our first quarter 2023 adjusted EBITDA would have been approximately $350,000 lower. For the full year of 2023, we do not expect these costs to have a material impact on our adjusted EBITDA guidance.

As always, please refer to our earnings release and presentation for a reconciliation of GAAP to non-GAAP metrics like adjusted EBITDA, which now reflects this change in historical periods.

Second, given the Steward acquisition in November, I will primarily focus on quarter-over-quarter comparisons of financial figures, which we find more useful for interpretation than year-over-year comparisons. Second quarter total revenue was $224 million, growing 30% compared to $173 million in the first quarter.

Medicare Risk revenues were $155 million, growing 28% from $122 million in Q1. Recall that Q1 Medicare risk revenues were unfavorably impacted by $27 million of prior year development related to historical membership in one of our MSO plans.

Normalized for this, Medicare risk revenues grew 5% from Q1, driven primarily by favorable trends in patient volume. Medicaid risk revenues increased 17% from $26 million in Q1 to $30 million in Q2, as favorable development in revenues more than offset the impact of a roughly 10% decline in Medicaid risk membership from redeterminations.

We expect Medicaid membership to continue to decline over the remainder of the year. In particular, we have observed this enrollment in patients with low premium funding and low utilization, driving an increase in blended revenue PMPMs and a decrease in medical margin PMPMs.

These dynamics were contemplated in our guidance, although average acuity has normalized faster than we anticipated toward pre-COVID levels. Government revenues increased from $10 million in Q1 to $22 million in Q2.

As a reminder, government revenues represent accruals of projected MSSP and ACO REIT shared savings, which we periodically revised based on updated estimates from our independent actuaries.

We believe our efforts around risk adjustment, care management and quality are favorable drivers to shared savings and performance year 2023 and would expect shared savings rates to be at least as much as those expected in performance year 2022.

Finally, other revenue grew 6% from $16 million in Q1 to $17 million in Q2, driven by growth in surpluses under partial risk contracts and accruals of quality incentives.

Medical expense ratio, defined as external provider costs divided by Medicare and Medicaid risk revenues was 84.6% in Q2 and 80.4% in the first half impacted by prior year developments in Medicare and Medicaid.

First, recall that last quarter, we recognized $15 million of unfavorable prior year development from the MSO plan membership and an earlier Flu and RSV season in South Florida.

Second, as Carlos mentioned, this quarter, we recognized $7 million of Medicaid prior year development related to data limitations from a single health plan that was acquired by a national payer. We have a long-standing relationship with this payer and are an anchor provider for them in the key Florida market.

Based on our conversations with the payer, we believe the health plan underwent system migrations that caused us to be unable to receive adequate data for its membership over a period of time, limiting our ability to manage that population.

As those issues resolved, we received 2022 data that gave rise to the unfavorable development recognized this quarter. We have since identified action items to get the performance under this plan back on track and also reached an agreement to improve financial terms of our contract with the payer.

You can follow these moving pieces in the supplemental slides of our earnings presentation. As you can see, we believe certain prior year developments had a total impact of approximately $21 million on first half adjusted EBITDA and 450 basis points on medical expense ratio.

Remember, that is our strategy to elect into full-risk MSO Medicare plans that are dollar profitable, even if they are running initially at higher MERs. We estimate that the mix of MSO contracts in our full risk population impacted MER by 220 basis points.

Additionally, the Benefits Cards had an estimated incremental impact of about 190 basis points, which we anticipate to impact MER through the remainder of the year. Beneficiaries have the discretion to use these Flex Cards for a wide range of medical and nonmedical purposes.

The use of Benefit Cards and overall higher enhanced supplemental benefits impacts our external provider costs and MER under a different type of expense that we would historically consider Part A and B medical utilization. In response to the enhanced supplemental benefits, we are proactively refining our offering to align with these changes.

By closely collaborating with the , we aim to make necessary adjustments that maintain the quality of our services for seniors, while effectively managing the costs related to these supplemental benefits. For these reasons, we are encouraged that underlying utilization in our core centers remains within the band of historical targets.

I'll now discuss what this means for EBITDA. Adjusted EBITDA was $7 million in the second quarter and $6.6 million in the first half. Adjusted EBITDA was burdened by $6 million of de novo preopening costs and post-opening losses in each of Q1 and Q2, and the $21 million of prior year developments in the first half.

While there are some sequential headwinds compared to the first half, such as ongoing impact of Medicaid redeterminations -- we believe there are still mechanical drivers of favorable back cash seasonality, such as pharmacy limitations and more patients hitting stop-loss injectables that will allow us to meet the midpoint of our guidance range despite the $21 million of prior year developments.

At this time, we have conservatively assumed our base case claims experience for the remainder of the year to be similar to the first half. Including another early Flu season and the winter that may or may not occur and consistent utilization of Benefit Cards among our population.

In addition, we have maintained a disciplined pace of investing in our de novo centers and continue to expect preopening costs and post-opening losses to be about $25 million for the year.

On revenue, due to our early election of full risk and certain MSO plans, we are raising guidance to $750 million to $800 million for the year from $700 million to $750 million.

We've more than doubled our revenue base over the past 2 years and believe we are well on our way to executing on our estimated $3 billion of embedded premium under management.

Cash used in operating activities was $24 million in the second quarter, flat compared to Q1 despite higher cash interest and ramping investments across our consolidated business. As a reminder, we typically expect cash flow for Medicare risk contracts to improve in the second half compared to the first half due to the midyear and final suites.

In addition, we expect to receive proceeds from MSSP shared savings later in the year, most of which will go towards repayment of the AR facility entered into at the time of the Steward acquisition. We ended June with $55 million in cash and equivalents, which includes our draw of the remaining $35 million of our original DDTL in April.

The upside $60 million DDTL we secured in the first quarter remains fully undrawn.

Our leverage ratio as of the second quarter was comfortably within covenants, and we expect to be able to draw that additional DDTL to fund our cash needs to the fourth quarter of 2024, when we will be able to keep the full proceeds of the 2023 government program shared savings.

Despite the headwinds in our reported results, we remain confident in our liquidity outlook and excited to unlock the earnings potential in our portfolio of contracts. Operator, we are ready for questions..

[Operator Instructions]. Your first question comes from the line of Andrew Mok of UBS..

First, just wanted to flesh out the underlying drivers of Medicaid PYD in the quarter that you called out.

Can you help us understand whether this was related to the Medicaid redeterminations in any way? And how is this experience impacting your forward view on pricing and utilization?.

Andrew, it's Kevin. Yes. The prior year development of $7 million that we referenced here has nothing to do with the redetermination. This is strictly isolated to one health plan where we had some data issues -- we are seeing that the redeterminations are kicking in. We lost about 10% of our Medicaid full-risk population during the quarter.

We've baked in those higher MERs that we've seen now related to prior year development into our forward-looking forecast. And so all of that has been taken into consideration then as part of our guidance of $25 million to $35 million..

Just add to that. It was really a migration of data. It was an acquisition of a health plan by a national payer and that data migration just caused some issues with the data. So then when we got the more credible and more accurate or more real-time data that's reflected in that and that for that period of time, whether we're migrating that data..

Got it. Okay. And then I think in your prepared remarks, you mentioned that Medicare outpatient utilization has started to moderate.

Can you go into a little bit more detail on what you're seeing there and over what time period you're referring to when you say outpatient trends ticked up and ticked down? I think there's a pretty meaningful delay in the claims data that you see..

Yes, Andrew, it's so we did look into that. We do have a little bit of a delay in the claims data. We're typically about 30 days behind the health plan when they see the information. The uptick that we're seeing really happened towards the end of March, we do have a little bit of a delay from getting health plan information.

However, we do have real-time information on our referral patterns and are able to look at that information to determine whether we anticipate spikes in outpatient care..

Your next question comes from the line of Brian Tanquilut of Jefferies..

You've got Taji on for Brian. So first, going back to the MER discussion, Kevin, thank you for the detail on all moving pieces that impacted the higher MER that we saw this quarter. I'm just curious, I know that you had called out the PYD and triggering switch to full risk as a few reasons. I'm not sure if I missed this.

Did you call out any contribution from that higher outpatient utilization? Like how much of that contributed to the uptick in MER this quarter?.

No, we actually didn't -- we didn't call that out specifically. It's hard to isolate one or two periods on the outpatient and look at that as kind of recurring. What we've seen is that the utilization has come back to normal -- there's always ebbs and flows within the data.

There's a seasonality component to the utilization what we have anticipated, is this maybe just a little bit of a pull forward of utilization that we would typically see in the third quarter. Which is why from our standpoint, a little bit of a blip on the outpatient side and kind of coming back to normal.

I think it's important also to note that inpatient trends are significantly favorable over our anticipation. Our anticipated utilization and cost for admins are in line with historical. So I think as you think about the costlier events that would happen, those events are being managed very well.

The outpatient side is one of those ones where you do have the seasonality components that kind of flow through the year..

Great. That's really helpful. And then kind of shifting to MA risk-based revenues. So I hope you added an additional 7,000 MA members and roughly 2,500 in full risk.

May be helpful if you could provide some more granular detail on how the PMPMs are trending at full risk versus the other value-based bucket? Just want to check by my math and see the full risk PMPMs stepped up quite a bit sequentially. So I just want to make sure I have that right. So if you can provide any color, that would be helpful..

Yes, absolutely. We did see an uptick in the full-risk premiums this year. Some of that does have to do with, obviously, our -- we talked about the impact that COVID had on our ability to adequately document the acuity of the population. So we are seeing those tailwinds impacting.

The other component really is around the supplemental benefits and the bids that the health plans push through, just the base premiums we're seeing increase to kind of cover some of these additional gift cards as well..

Your next question comes from the line of Jalindra Singh of Truist Securities..

This is Eduardo on for Jalindra. Just around all the talk around potential pent-up demand utilization.

Just curious to see if you're seeing what you're seeing in your Florida market and in your Steward market and if there's any major differences to call out?.

No. I don't know that we've seen a huge pent-up demand. I do think that we saw that uptick and utilization that we called out here in this call that we've since seen normalized across. And we expect it to stay normalized throughout the next quarter. And that could just be some seasonality changes.

And if you'll remember, we did have some seasonal changes on our RSV and Flu season last quarter typically recognized in Q1, we generally saw that utilization in Q3, Q4 of last year. So some potential kind of seasonal changes in some of the trends of some of these different dynamics that are going on..

Okay. And I guess just second half -- your second half revenue outlooks implies a bit of a moderation from the Q2 run rate, while you continue to expect to add more Medicare lives throughout the end of the year.

Can you just explain what the moderation in revenue relates to?.

Sure. Edward, this is Kevin. Yes. So as we look at -- there's a few items that are impacting that.

There's -- yes, we're adding 2,500 or so patients throughout the end of the year, maybe even a little more -- but typically, the second half of the year, the PMPMs trend down just because of your more acute patients are expiring, you're typically bringing on new to Medicare patients, which tend to be healthier for patients that may not necessarily have adequate documentation from a coding standpoint.

So the premiums tend to trend down from a PMPM standpoint, those for the Medicare risk population somewhat neutralized, maybe a slight negative trend.

I think the bigger factors are really around on the MSSP side, where the patients -- you filled the bucket kind of at the beginning of the year and then there's selection where patients again expire or they select MA plans. And those tend to trickle down. So we do expect MSSP membership to wind down a little bit.

And then in addition to that, the Medicaid redeterminations, we are expecting membership to continue to decline there. Those are somewhat lower premium patients. They tend to be the TANF patients. But we do anticipate that, that membership the combination of that with the MSSP to contribute to less of revenue for the second half..

And just important to note that this is normal course of business due to kind of the history of managed care, right, as you think about how MSSP works and how your bucket is refilled at the end of the year through that attribution formula that CMS uses.

And then again, on the Medicare Advantage side, as all of the members that you're starting the year with have all been flow through your system, have captured that acuity of that membership and as you bring on those new membership that dilutes a little bit of that risk or so you bring down that.

So -- so all of this that we experienced towards the second half of the year is just normal course of what we consider value-based care..

Your next question comes from the line of Jessica Tassan of Piper Sandler..

So I was just hoping maybe on the prior year development for the Medicaid contract. Just can you kind of, I guess, just what changes were made to that contract or the economics of that contract that kind of justify the contracts persistence despite the materiality of the prior year development? That would be my first question..

I think I'll just start with -- look, this is a relationship we've had for a very long time. It's a very strong partners of ours and -- so there were some changes made. We manage a lot of different lines of business for them, ACA, the Medicaid and the Medicare.

So we took a look at all of the different contracts that we had and we're able to make significant material changes that we believe just improves our run rate moving forward and then kind of help us kind of through that -- through that issue.

So I think where we landed ultimately is more favorable in the long term for the business -- across all lines of business..

Okay. Got it. And so then maybe can you just help us understand what is kind of a normalized Medicaid full-risk MER? And then what is your expectation in the back half of the year and kind of heading into 2024? If there is one for -- or just have the impact -- adverse impact of redeterminations on that normalized MER..

Jessica, it's Kevin. Yes, so we do anticipate the MER to increase in the back half. The premium -- the actual premium PMPM for the blended population should increase.

What we've seen kind of since the PHE started is the TANF population tends to be a lower premium population is what caused the increase in membership, if you will, which diluted down our revenue PMPMs -- and so now that, that population has to go through the redetermination component of it, there's going to be tranches of the population that are just going to not be eligible for Medicaid anymore.

So the PMPMs will the premium PMPMs will definitely increase. It will blend back up to what we've kind of pre-COVID levels is what we would anticipate. MERs', we would anticipate those also to increase Medical margin, I would say, is going to decline. It won't be a significant decline because of the fact that these are higher premium patients.

And despite the fact that they have higher MERs, the MER sorry, the platform contribution or PMPM from a margin standpoint would deteriorate, but just a little bit. So I think as we look at it, we're -- call it the 70, mid-70s range. We would anticipate that to go back to kind of pre-COVID levels, which would be closer to that mid- to low-80% range..

Got it. And that happens over the back half of '23 or heading into '24? And then just my last question would be with respect to kind of the heat wave we've seen this summer.

I'm curious if you're seeing any incremental kind of ER utilization or inpatient expenses related to that heat wave, especially in South Florida?.

Yes. Just to answer your last question, yes, or the first part of your last question, you're right, the back half of the year is when we anticipate there is redeterminations kicking in. We haven't seen anything from a utilization standpoint on the ER side or an uptick in the ERs specifically related to the heat wave.

It's one of those things that we constantly are looking at. We do get live data feeds from the ENS, which is the event notification system here in Florida. And we do get that information once the patient kind of hits the ER, so we're able to track them through. Those seem to have stabilized or somewhat normal.

So nothing to report or expect at this point..

Yes. I think if you're going to -- the only issue that we see really in the South Florida market, it's more on the Flex Cards, right, the supplemental benefits, not on the utilization side.

And some of the things that we're doing to mitigate that is we're working -- we do have certain enhanced benefits at some of our medical centers that have been enjoying some of those services, and we're working with the health plans now and potentially now that they have access to that using those flat cards, potentially just using those Flex Cards to either acquire or purchase those services or remove them from the centers if they're already receiving it through the Flex Card.

So there's a lot of different things that we can do to mitigate that moving forward as the -- we don't know that the -- we think the Flex Cards are here to stay, and then we've talked to several health plans and there may be some changes in those benefits.

But ultimately, we believe that there are various ways where we can mitigate that moving forward to impact the company much more favorably..

[Operator Instructions]. Your next question comes from the line of Joshua Raskin of Nephron Research..

I think, I want to stay on that topic actually, Carlos.

The -- I'm curious, this utilization of supplemental benefits and if that's trended any differently in 2Q versus 1Q? And as you start thinking about that landscape, and how it changes for 2024? Maybe specifically, how are you working with payers? And what are the key points that you're trying to get across that you think CareMax needs to be successful for next year?.

Yes. I think the more difficult part of some of these Flex Benefits is in the utilization and the way that they're used where -- in the past, these were done on a monthly basis and now there's more flexibility around that usage. So you do see where some benefits aren't used in Q1 and then all of a sudden, they're using a cumulative way. And in Q2.

So we did see a little bit of that. I think the way we're working with health plans and we've been connecting with all of the major health plans on this is how do we offset some of these Flex Card benefits or potentially bring down some of these supplemental benefits.

The health plans are working in some way or another to offset some of these benefits, either through the Flex Card or through some other mechanism of reduced benefits.

However, as I was mentioning to Jessica, I think there's a huge opportunity for us now because of the way that we delivered our care in our fully integrated centers and these additional benefits that we were offering our members, especially because most of these members are do audible in these areas.

And don't have access to food and meals and many other things is using these Flex Cards to provide those benefits, in essence, no longer kind of double paying for a lot of this.

So -- these are some of the things that we're exploring internally and with the health plans to mitigate this moving forward, and we think there's a much better path forward, and we're working aggressively to get that implemented as soon as possible..

Are you noticing a change in tone? Obviously, there's some headwinds in 2024 around risk adjustment and the actual level of reimbursement, a couple of your payer partners have some significant star headwinds as well.

Is that -- is that conversation changing the way? Are you looking at things like a higher percentage of premium cap and other sort of wholesale changes?.

Yes. In some cases, we've already been able to achieve that, right, going forward. To offset some of those potential Star headwinds. I think on the risk adjustment side, and the rate letter, I think we're working with some of these health plans.

I think the fact that it's a phased-in approach, it shows the commitment from CMS on Medicare Advantage, but it also allows us and the health plans to react to this from a benefit design plan, and that's been kind of the majority of the conversations have been around that and the utilization and the Flex Cards on how do we plan over the next 2, 3 years to ensure the most minimal impact as we're thinking about it now, that impact is somewhere from what we're thinking about next year at a 5% increase to now probably potentially a 2% increase in rates.

And look, I think the other thing that we've done very well is we have grown extensively. We've diversified our business. I think the biggest impact will probably be in some of the South Florida dual population.

But because we have so much concentration now in so many different states, a lot which are not eligible through that Steward acquisition that come at a very low score. I think for our organization, specifically, there's a tremendous amount of upside to capitalize on this moment..

Yes. And then just last one, Carlos. As we think about the jumping off point for 2024 -- should we be thinking about midpoint of guidance and then added in $21 million in negative development sort of that $50-ish million range.

Is that the right jumping off point for how we want to think about EBITDA growing whatever, pluses or minuses into 2024?.

Yes. I think when you think about 2024 right now, we're not changing anything from what we discussed today on Investor Day presentation. We feel very confident in the targets that we put out and the long-term guidance.

Look, I think when you're growing the way we grew, right, we went from 20,000 members to managing over 200,000 members in a 2-year period. There's going to be a couple of blips along the way, but our trajectory is incredibly positive.

We feel excited about the business and still feel confident in kind of the cases that we laid out on the Investor Day presentation. So I think that's how we should be thinking about the business moving forward. And sure, there'll be some -- it's not going to be a straight line up just because there's been so much growth.

But overall, our performance in the core business continues to be very, very strong. overall, our performance on the de novo business. We've already grown our business that had no members to over 4,000 expecting to end the year 5,000 members over 17 centers.

And then obviously, the acquisition, the MSSP opportunity there is already showing potentially more positive performance and then moving forward with all the adjustments and everything that we're implementing. From our managed and value-based care is positive. So we're very bullish on the outlook over the next several years for the company..

There are no further questions at this time. I will now turn the call over the call to Carlos de Solo for closing remarks..

Thanks. Yes. On behalf of the CareMax team, we just want to thank everybody for joining the call today. We look forward to updating you on the progress and have a great day, everyone..

This concludes today's conference call. You may now disconnect..