Patient Coverage Connect

Investor Overview — Confidential

Every day, Medicare beneficiaries sit in a doctor's office or a pharmacy enrolled in the wrong plan — and the clinical data to identify that is already in the room, connected to nothing.

Patient Coverage Connect automatically surfaces Medicare coverage gaps from clinical data that already exists — at the point of care, or before the patient ever arrives. It connects them to a Medicare advisor who already knows everything. The data was always there. Now it's captured.

"My providers send me the ones that need something. All I do is solve their problems — and I accidentally make money all day."

— Scott Woods, Founder

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The advisor — visible in their patient portal

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‹ Insurance Summary Close

Coverage Overview

Humana Gold Plus H1036 / Medicare Advantage HMO

✓ Information from Humana. Prices may vary.

SubscriberRobert T. Hollis

Member IDH10360041882

⚠️

Formulary change. Eliquis moved to Tier 4. Now $180/fill vs. $8. Annual cost increase ~$2,064. No therapeutic equivalent.

💊Prescription Drug Coverage (Part D)

Levothyroxine 200mcg

Thyroid · 30-day supply

$8/fill

Tier 1

Apixaban (Eliquis) 5mg

Blood thinner · AFib

$180/fill

Tier 4 ↑

Allopurinol 300mg

Gout · 30-day supply

$8/fill

Tier 1

ℹ️

You may qualify for Extra Help with prescription costs. Ask your advisor.

Your Medicare Advisor

Jenny Woods

Rural Health Advisors

👨‍⚕️ Your Care Team Coverage

The Vision — Future Phase
The advisor embedded directly inside the patient's portal — MyChart, athenaOne, Oracle Health, and others. The agent relationship becomes part of the clinical record.

The Platform

Automatic. Before the appointment.
Before the crisis.

Patient Coverage Connect operates in two tiers. PCC Direct — available soon — is a lightweight referral interface usable by any provider regardless of EHR. Staff identifies a coverage question, downloads the patient's clinical summary, confirms permission, and submits. Simple and self-service. PCC Integrated adds automated coverage gap detection embedded directly in the EHR — surfacing formulary changes, low-performing plans, SNP eligibility, T-65 events, and plan terminations automatically, before the patient even arrives.

The gap is found — automatically or by staff

In PCC Integrated, clinical records are scanned automatically — surfacing formulary changes, low-performing plans, SNP-qualifying diagnoses, T-65 events, plan terminations — before the appointment, before the patient knows. In PCC Direct, staff identifies the question and submits. Both tiers deliver the same fully briefed referral.

The referral is built in seconds

When a coverage question arises — identified by staff or raised by the patient — the clinical record is parsed instantly. Medications, diagnoses, current plan, income indicators where available in the record. The referral packet is built without manual data entry. Patient gives permission, documented with a timestamp.

The advisor arrives knowing

The Medicare advisor receives a complete clinical brief before making contact. No cold calling. No discovery. No wasted appointments. The advisor already knows the patient's medications, diagnoses, current plan, and exactly why they were referred.

Embedded in the patient portal — future phase

The advisor's photo and a coverage review button embedded inside the patient's portal — MyChart, athenaOne, Oracle Health, and others. The patient initiates a review. The agent relationship becomes part of the clinical record. This is the platform's next development horizon.

What makes this different

🏥

Clinically sourced

Referrals originate inside clinical workflows — physician offices and pharmacies. The highest-trust setting in healthcare.

⚡

First to know — automatically

PCC monitors plan reference data continuously. When a plan terminates, the system cross-matches affected patients across all participating EHRs — before the clinic knows, before the patient's letter arrives. Staff activation and system-assisted identification are both live paths.

📋

Pre-qualified and fully briefed

The advisor receives medications, diagnoses, current plan, and the specific coverage question — before making contact. No other lead channel in Medicare distribution does this.

✓

Carrier-agnostic

Works across all Medicare plan types. Not tied to any carrier. The lead source that was always there — now captured.

The Problem

Providers are plagued by coverage problems they cannot solve.

Every clinical setting is confronted daily with coverage failures that slow care, harm outcomes, and burden staff. Providers try to connect patients to resources — Extra Help, better plans, subsidy programs — but the system is fragmented and unstreamlined. Most coverage problems leave the office unresolved. Until now.

💊

Patients rationing medications because their plan moved their drug to a higher tier

A formulary change the patient never understood is affecting their adherence — and the provider's outcomes scores. The clinical record shows exactly which patients face this. The system finds it automatically.

HEDIS: Medication Adherence — Statins, Diabetes, Hypertension

🏥

Specialists and facilities outside the plan network

The referral the physician just wrote may not be coverable. The patient won't find out until they receive a bill. Diagnosis codes in the clinical record identify who faces this — before the appointment.

STAR: Plan All-Cause Readmissions (3× weight, 2025)

📅

Patients approaching Medicare eligibility with no one to guide them

T-65 patients make expensive, irreversible decisions without guidance. They don't know where to turn or who to trust. The provider knows. Now there's a systematic answer.

STAR: Care for Older Adults

💰

Patients paying full drug costs when assistance programs could cover them

Pharmaceutical patient assistance programs and disease foundations can dramatically reduce or eliminate drug costs for qualifying patients. Providers try — but navigating dozens of programs is fragmented and time-consuming.

HEDIS: Medication Adherence — income-eligible population

📋

Chronic condition patients in the wrong plan type

A patient with diabetes or COPD may qualify for a Chronic Special Needs Plan with far better coverage. The diagnosis codes are in the record. Without this platform, they stay there.

HEDIS: Comprehensive Diabetes Care, Controlling Blood Pressure

🔄

Plans terminating or leaving the service area

The patient learns this from you — because the letter they received meant nothing to them. They don't know where to turn or who to trust. Now there's a systematic answer.

STAR: Member Experience / CAHPS

How It Works

From clinical record to informed advisor
in seconds.

The platform works automatically from clinical data that already exists. When a gap is surfaced — automatically or by staff — the patient gives permission, documented with a timestamp. The advisor receives a complete clinical brief before making contact.

🔍

Gap identified

Platform surfaces coverage problem from clinical record — automatically, or when staff submits a referral

📋

Record parsed

Clinical record parsed instantly — medications, diagnoses, current plan, income indicators where available — no manual data entry

⚡

Advisor briefed

Medicare advisor receives a complete clinical brief before making contact — the highest-value lead ever delivered in Medicare distribution

✓

Patient helped

The advisor arrives knowing. The patient gets the right plan. The provider's coverage problem is resolved.

Market Opportunity

The lead source that was always there.
Now captured.

Why provider referrals are the best leads in Medicare — and always have been

Internet leads are bought, sold, and recycled. A clinical referral is warm, specific, trusted, and accompanied by a clinical brief no other channel can provide.

The patient has already identified a need in a setting they trust, with permission documented. The advisor arrives knowing the patient's medications, diagnoses, current plan, and the specific coverage question that triggered the referral.

Highest conversion rates of any Medicare lead type
Clinical brief eliminates discovery — advisor goes straight to solutions
Permission documented with timestamp
Advisor relationship begins with trust, not a cold call
Every clinic generates referrals continuously — self-replenishing
Carrier-agnostic — MA, PDP, supplement, and social programs that seed future Medicare leads

The channel that was always there

Provider referrals have always been the highest-quality Medicare lead source. They have also always been entirely analog — a sticky note, a phone number on a prescription pad, a conversation that went nowhere.

Patient Coverage Connect systematizes this channel for the first time. The infrastructure didn't exist. Now it does.

The validation is already happening

In July 2025, Epic launched a carrier-specific integration allowing coverage information to surface inside patient portals for one major Medicare Advantage plan. This confirms the largest EHR vendor in the country sees the same opportunity. Patient Coverage Connect is carrier-agnostic, works across all plan types, and requires no EHR integration to operate today.

Distribution infrastructure already in place

Rural Health Associations nationally have expressed willingness to promote PCC to their members once the platform is released, built on a decade of provider relationships and four-state agency operations. Provider onboarding is simple and self-service — a provider is live in under an hour.

Business Model

Premium leads. Per referral.
The accidental revenue model.

The Medicare lead market is built around "leads cost X." Patient Coverage Connect enters at the premium end of that market. Clinical sourcing, pre-qualification, and conversion rates no other channel can match justify the highest per-lead pricing in the market.

Lead Fee — Every First Contact

Every patient's first referral through Patient Coverage Connect carries a premium lead fee — for new patients and existing agent-of-record relationships alike. The AOR check does two things simultaneously: it identifies who the patient's existing advisor is, and asks whether they're enrolled in the lead program with availability set. If yes, routes to them at full price. If not, routes to the next available advisor in the campaign.

FMOs may co-op or sponsor lead costs as a retention and recruitment tool.

Premium Highest per-lead pricing in Medicare distribution

Ongoing Relationship — $0

Once an advisor has paid for a patient lead and engaged, all future referrals for that patient route back to them at no charge — for as long as the AOR relationship remains active and uninterrupted in their CRM. If the relationship lapses, the next referral resets to full price.

Advisors can tell their entire book of record to hit the Request Review button in their patient portal each year. Every client who does sends the advisor their latest clinical information as a free, fully briefed lead. An entire book of record, re-engaged annually, at no cost.

$0 All subsequent leads while AOR is active and uninterrupted

The Accidental Revenue Model

Clinical workflows generating Medicare coverage referrals will continue whether or not Patient Coverage Connect exists. The platform captures value from activity that was already happening — and going nowhere. Social program referrals that begin as Extra Help navigation become Medicare coverage leads as patient circumstances change.

Every clinical encounter with a Medicare patient is a potential revenue event. The system runs continuously.

67M Medicare beneficiaries — the addressable pool

Regulatory Tailwinds

Correct plan placement is a quality measure intervention.

Every referral that results in correct plan placement directly affects the HEDIS measures that determine Medicare Advantage STAR ratings — and the hundreds of millions in quality bonuses those ratings control. Correct plan placement directly affects the HEDIS and STAR measures that determine quality bonuses — and the downstream clinical outcomes that affect provider reimbursement.

HEDIS — Medication Adherence

Statins · Noninsulin Diabetes Medications · RAS Antagonists

These three medication classes are the core HEDIS adherence measures for Medicare Advantage plans. Patients in wrong Part D plans who cannot afford their medications fail these measures. Correct plan placement directly restores adherence. Note: CMS temporarily reduced the weight of these measures from 3× to 1× for 2026 while implementing social determinants risk adjustment; they return to full weight in 2029.

STAR — Plan All-Cause Readmissions (3× weight, 2025)

Coverage Gaps Drive Avoidable Readmissions

Patients who delay care due to coverage problems get sicker and get readmitted. CMS increased the readmission measure weight from 1× to 3× for 2025 STAR ratings. Every referral that resolves a coverage gap before the patient deteriorates is a direct readmission prevention intervention.

HEDIS — Comprehensive Diabetes Care

Chronic Condition Patients in the Right Plan

Patients with diabetes who are not in plans designed for their condition miss care management support, medication coverage, and specialist access. Diagnosis codes in the clinical record identify these patients automatically. A Chronic Special Needs Plan referral changes their coverage profile — and their plan's STAR performance.

STAR — Care for Older Adults · Member Experience

Functional Outcomes and Patient Satisfaction

Coverage gaps that go unresolved accelerate functional decline and erode member experience — both tracked STAR measures. Connecting patients to correct plans, appropriate subsidies, and advisors who arrive knowing their situation improves both clinical outcomes and the member satisfaction scores that drive STAR ratings.

Current Status

Where we are right now.

PCC Direct — available soon

Referral workflow and staff authentication are functional. Built on HIPAA-compliant infrastructure. No EHR integration required to operate. Launching Summer 2026.

Clinical partner in discussions

Erlanger Health System — 28 primary care clinics across three states — is in active pilot discussions. No cold outreach required. The coverage problem is real and the health system recognized it immediately.

FMO integration in progress

Integrity Marketing Group — the largest Medicare FMO in the US — is in active API integration discussions. Additional FMO conversations underway.

Field force scale-up in planning

Building the national organization for provider onboarding and advisor certification. National in scope — activating as clinical partners come online.

Launch imminent

Upon completion of FMO API integration, the first clinical locations launch. Conversion data sets the premium lead price and validates the model for scale.

Seeking strategic capital

Looking for a partner who understands Medicare distribution and can accelerate the provider network build. This is not a technology bet. It is a distribution and timing bet — and the pieces have come together.

Automatic. Before the appointment.Before the crisis.