CareMax Reports Third Quarter 2023 Results

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CareMax, Inc. (NASDAQ: CMAX; CMAXW) (“CareMax” or the “Company”), a leading technology-enabled value-based care delivery system, today announced financial results for the third quarter ended September 30, 2023.

“Tomorrow marks one year since the acquisition of our national MSO and nearly two and a half years of rapid growth in our patient and provider base. Over that period, we experienced fluctuations in our revenue and EBITDA as we underwent numerous initiatives to integrate that membership. With significant progress made in many of those initiatives, we have increased confidence in our ability to effectively manage our members on their glidepath to risk and operate toward more consistent financial outcomes. Looking ahead, we feel well positioned to navigate the evolving utilization environment and execute on the embedded value in our platform,” said Carlos de Solo, Chief Executive Officer.

Third Quarter 2023 Results

Total membership of 273,000, up 194% year-over-year.
Medicare Advantage membership of 107,000, up 171% year-over-year.
Total revenue was $201.8 million, up 28% year-over-year.
Net loss was $103.1 million, including $80.0 million of non-cash goodwill impairment, compared to net loss of $22.1 million for the third quarter of 2022.
Adjusted EBITDA was $2.1 million, compared to $4.4 million for the third quarter of 2022.¹
Platform Contribution was $21.1 million, compared to $20.6 million for the third quarter of 2022.¹
Medical Expense Ratio was 88.0%, compared to 75.2% for the third quarter of 2022.
De novo pre-opening costs and post-opening losses for the third quarter of 2023 were $5.8 million.²

Financial Outlook for Full Year 2023

CareMax is reaffirming the following full year 2023 guidance:

Total revenue of $750 million to $800 million, up 19% to 27% year-over-year.
De novo pre-opening costs and post-opening losses are anticipated to be approximately $25 million in 2023.

CareMax is updating the following full year 2023 guidance:

Year-end Medicare Advantage membership of approximately 110,000, up 18% year-over-year.
Adjusted EBITDA of $15 million to $25 million, compared to $19.1 million for the year-ended December 31, 2022.¹

¹ Adjusted EBITDA and Platform Contribution are non-GAAP financial metrics. A reconciliation of non-GAAP metrics to the most directly comparable GAAP financial measures is included in the appendix to this earnings release. Beginning with the three months ended June 30, 2023, the Company has updated its calculation of Adjusted EBITDA on a retrospective basis to no longer add back certain compensation costs for stay-on bonuses and duplicative salaries previously included within the Business Combination integration costs adjustment. Adjusted EBITDA as previously reported for the third quarter of 2022 included an addback of $0.9 million for stay-on bonuses and duplicative salaries. Adjusted EBITDA as previously reported for the year ended December 31, 2022 included an addback of $2.9 million for stay-on bonuses and duplicative salaries.

² De novo pre-opening costs represent (1) incremental payroll costs from employees specifically associated with the operational, contractual, physical, or regulatory infrastructure for de novo centers, prior to their opening; (2) legal costs directly associated with the de novo centers, incurred prior to their opening, which includes services such as execution of leases, health plan contracts and other agreements; (3) other expenses related to diligence, design, permitting, and other “soft costs” at new sites; and (4) rent and facility expenses prior to center opening. De novo post-opening losses include center-level operating losses recognized at a de novo center until the center breaks even, up to 18 months after opening, which consist of revenue, external provider costs and cost of care allocated for the de novo center.

Conference Call Details

Management will host a conference call at 8:30 am ET today to discuss the results. The conference call can be accessed by dialing (888) 330-2508 for U.S. participants, or (240) 789-2735 for international participants, and referencing conference ID 7874605. A live audio webcast as well as related presentation materials will also be available on the “Events & Presentations” section of CareMax’s investor relations website at ir.caremax.com. Following the live call, a replay will be available on the Company’s website.

About CareMax

Founded in 2011, CareMax is a value-based care delivery system that utilizes a proprietary technology-enabled platform and multi-specialty, whole person health model to deliver comprehensive, preventative and coordinated care for its members. With over 200,000 Medicare Value-Based Care Members across 10 states, and fully integrated, Five-Star Quality rated health and wellness centers, CareMax is redefining healthcare across the country by reducing costs, improving overall outcomes and promoting health equity for seniors. Learn more at www.caremax.com.

Forward-Looking Statements

This press release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, Section 21E of the Securities Exchange Act of 1934, as amended, and the Private Securities Litigation Reform Act of 1995, as amended. These forward-looking statements include statements regarding our future growth, strategy and financial performance. Words such as “anticipate,” “believe,” “budget,” “contemplate,” “continue,” “could,” “envision,” “estimate,” “expect,” “guidance,” “indicate,” “intend,” “may,” “might,” “plan,” “possibly,” “potential,” “predict,” “probably,” “pro forma,” “project,” “seek,” “should,” “target,” or “will,” or the negative or other variations thereof, and similar words or phrases or comparable terminology, are intended to identify forward-looking statements. These forward-looking statements reflect the Company’s expectations, plans or forecasts of future events and views as of the date of this press release. These forward-looking statements are not guarantees of future performance, conditions or results, and involve a number of known and unknown risks, uncertainties, assumptions and other important factors, many of which are outside the Company’s control, that could cause actual results or outcomes to differ materially from those discussed in the forward-looking statements.

Important risks and uncertainties that could cause the Company’s actual results and financial condition to differ materially from those indicated in forward-looking statements include, among others, the Company’s ability to integrate acquired businesses, including the ability to implement business plans, forecasts, and other expectations after the completion of the Steward transaction; the failure to realize anticipated benefits of the Steward transaction or to realize estimated pro forma results and underlying assumptions; the impact of COVID-19 or any variant thereof or any other pandemic or epidemic on the Company’s business and results of operation; the Company’s ability to attract new patients; the availability of sites for de novo centers and the costs of opening such de novo centers; changes in market or industry conditions, regulatory environment, competitive conditions, and receptivity to the Company’s services; the Company’s ability to continue its growth, including in new markets; changes in laws and regulations applicable to the Company’s business, in particular with respect to Medicare Advantage and Medicaid; the Company’s ability to maintain its relationships with health plans and other key payers; any delay, modification or cancellation of government contracts; the Company’s future capital requirements and sources and uses of cash, including funds to satisfy its liquidity needs and the Company’s ability to comply with the covenants under the agreements governing its indebtedness; the Company’s ability to address the material weakness in its internal control over financial reporting; the Company’s ability to recruit and retain qualified team members and independent physicians; risks related to future acquisitions; the Company’s ability to develop and maintain proper and effective internal control over financial reporting and the impact of any prior period developments. For a detailed discussion of the risk factors that could affect the Company’s actual results, please refer to the risk factors identified in the Company’s reports filed with the SEC. All information provided in this press release is as of the date hereof, and the Company undertakes no duty to update or revise this information unless required by law, and forward-looking statements should not be relied upon as representing the Company’s assessments as of any date subsequent to the date of this press release.

Use of Non-GAAP Financial Information

Certain financial information and data contained in this press release is unaudited and does not conform to Regulation S-X. Accordingly, such information and data may not be included in, may be adjusted in, or may be presented differently in, any periodic filing, information or proxy statement, or prospectus or registration statement to be filed by the Company with the SEC. Some of the financial information and data contained in this press release, such as Adjusted EBITDA and Platform Contribution and margin thereof have not been prepared in accordance with United States generally accepted accounting principles (“GAAP”). These non-GAAP measures of financial results are not GAAP measures of our financial results or liquidity and should not be considered as an alternative to net income (loss) as a measure of financial results, cash flows from operating activities as a measure of liquidity, or any other performance measure derived in accordance with GAAP. The Company believes these non-GAAP measures of financial results provide useful information to management and investors regarding certain financial and business trends relating to the Company’s financial condition and results of operations. The Company’s management uses these non-GAAP measures for trend analyses and for budgeting and planning purposes.

The Company believes that the use of these non-GAAP financial measures provides an additional tool for investors to use in evaluating projected operating results and trends in and in comparing the Company’s financial measures with other similar companies, many of which present similar non-GAAP financial measures to investors. Management does not consider these non-GAAP measures in isolation or as an alternative to financial measures determined in accordance with GAAP. The principal limitation of these non-GAAP financial measures is that they exclude significant expenses and income that are required by GAAP to be recorded in the Company’s financial statements. In addition, they are subject to inherent limitations as they reflect the exercise of judgments by management about which expenses and income are excluded or included in determining these non-GAAP financial measures. For this reason, these non-GAAP measures may not be comparable to other companies’ similarly labeled non-GAAP financial measures. In order to compensate for these limitations, management presents non-GAAP financial measures in connection with GAAP results.

A reconciliation for Adjusted EBITDA and Platform Contribution to the most directly comparable GAAP financial measures is included below. A reconciliation of projected 2023 Adjusted EBITDA to the most directly comparable GAAP financial measure is not included in this press release because, without unreasonable efforts, the Company is unable to predict with reasonable certainty the amount or timing of non-GAAP adjustments that are used to calculate this. In addition, the Company believes such a reconciliation would imply a degree of precision and certainty that could be confusing to investors. The variability of the specified items may have a significant and unpredictable impact on the Company’s future GAAP results.

CAREMAX, INC.
CONDENSED CONSOLIDATED BALANCE SHEETS
(in thousands, except share and per share data)
(Unaudited)

	September 30, 2023			December 31, 2022
ASSETS

Current Assets
Cash and cash equivalents	$	32,264		$	41,626
Accounts receivable, net		139,573			151,036
Risk settlement receivables		251			707
Related party receivables		754			—
Other current assets		3,820			3,968
Total Current Assets		176,662			197,336

Property and equipment, net		27,837			21,006
Operating lease right-of-use assets		130,826			108,937
Goodwill, net		522,643			700,643
Intangible assets, net		106,889			123,585
Deferred debt issuance costs		896			1,685
Other assets		92,363			17,550
Total Assets	$	1,058,117		$	1,170,743

LIABILITIES AND STOCKHOLDERS’ EQUITY

Current Liabilities
Accounts payable	$	9,345		$	7,687
Accrued expenses		14,999			16,854
Risk settlement liabilities		21,934			14,171
Related party liabilities		47			1,777
Related party debt, net		34,517			30,277
Current portion of third-party debt, net		355			253
Current portion of operating lease liabilities		8,555			5,512
Other current liabilities		8,589			790
Total Current Liabilities		98,341			77,322
Derivative warrant liabilities		983			3,974
Long-term debt, net		302,612			230,725
Long-term operating lease liabilities		117,668			96,539
Contingent earnout liability		—			134,561
Other liabilities		13,897			8,075
Total Liabilities		533,501			551,196
COMMITMENTS AND CONTINGENCIES
STOCKHOLDERS’ EQUITY
Preferred stock (1,000,000 shares authorized; one share issued and outstanding as of September 30, 2023 and December 31, 2022)		—			—
Class A common stock ($0.0001 par value; 250,000,000 shares authorized; 112,096,998 and 111,332,584 shares issued and outstanding as of September 30, 2023 and December 31, 2022, respectively)		11			11
Additional paid-in-capital		779,776			657,126
Accumulated deficit		(255,171	)		(37,590	)
Total Stockholders’ Equity		524,616			619,547

Total Liabilities and Stockholders’ Equity	$	1,058,117		$	1,170,743

CAREMAX, INC.
CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS
(in thousands, except share and per share data)
(Unaudited)

	Three Months Ended September 30,						Nine Months Ended September 30,
	2023			2022			2023			2022
Revenue
Medicare risk-based revenue	$	134,105		$	122,267		$	411,184		$	373,677
Medicaid risk-based revenue		23,950			19,852			79,630			59,914
Government value-based care revenue		28,067			—			60,284			—
Other revenue		15,721			15,551			48,169			33,278
Total revenue		201,843			157,670			599,267			466,869

Operating expenses
External provider costs		139,139			106,900			406,807			320,104
Cost of care		43,826			30,213			122,645			87,925
Sales and marketing		3,501			2,355			10,593			7,955
Corporate, general and administrative		19,282			21,687			64,021			58,728
Depreciation and amortization		6,833			4,573			20,237			14,538
Goodwill impairment		80,000			—			178,000			—
Acquisition related costs		34			494			108			3,549
Total operating expenses		292,615			166,222			802,412			492,799
Operating loss		(90,772	)		(8,552	)		(203,145	)		(25,930	)
Nonoperating income (expense)
Interest expense		(14,000	)		(6,088	)		(37,908	)		(11,712	)
Change in fair value of derivative warrant liabilities		1,450			(7,331	)		2,991			(3,476	)
Gain on remeasurement of contingent earnout liabilities		—			—			19,916			—
Loss on extinguishment of debt		—			—			—			(6,172	)
Other income (expense), net		376			99			1,097			(408	)
		(12,174	)		(13,320	)		(13,904	)		(21,768	)
Loss before income tax		(102,946	)		(21,872	)		(217,049	)		(47,698	)
Income tax expense		(177	)		(181	)		(532	)		(532	)
Net loss	$	(103,123	)	$	(22,053	)	$	(217,581	)	$	(48,230	)

Weighted-average basic shares outstanding		112,085,154			87,408,605			111,704,585			87,415,801
Weighted-average diluted shares outstanding		112,085,154			87,408,605			111,704,585			87,415,801
Net loss per share
Basic	$	(0.92	)	$	(0.25	)	$	(1.95	)	$	(0.55	)
Diluted	$	(0.92	)	$	(0.25	)	$	(1.95	)	$	(0.55	)

CAREMAX, INC.
CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS
(in thousands)
(Unaudited)

	Nine Months Ended September 30,
	2023			2022
CASH FLOWS FROM OPERATING ACTIVITIES
Net loss	$	(217,581	)	$	(48,230	)
Adjustments to reconcile net loss to cash and cash equivalents:
Depreciation and amortization expense		20,237			14,538
Amortization of debt issuance costs and discounts		6,422			1,093
Stock-based compensation expense		8,004			7,486
Income tax provision		532			532
Change in fair value of derivative warrant liabilities		(2,991	)		3,476
Gain on remeasurement of contingent earnout liabilities		(19,916	)		—
Loss on extinguishment of debt		—			6,172
Payment-in-kind interest expense		8,643			3,038
Provision for credit losses		382			—
Goodwill impairment		178,000			—
Amortization of right-of-use assets		8,872			—
Other non-cash, net		1,140			(774	)
Changes in operating assets and liabilities:
Accounts receivable		2,121			(43,109	)
Other current assets		148			(69	)
Risk settlement receivables and liabilities		11,020			(144	)
Other assets		(74,024	)		(1,037	)
Operating lease liabilities		(4,390	)		—
Accounts payable		(410	)		9,291
Accrued expenses		(1,855	)		6,705
Related party receivables and payables		(1,212	)		—
Other liabilities		14,414			1,222
Net cash used in operating activities		(62,446	)		(39,811	)

CASH FLOWS FROM INVESTING ACTIVITIES
Purchase of property and equipment		(8,007	)		(4,862	)
Return of cash held in escrow		—			785
Acquisition of businesses, net of cash acquired		—			(892	)
Net cash used in investing activities		(8,007	)		(4,969	)

CASH FLOWS FROM FINANCING ACTIVITIES
Proceeds from borrowings		62,000			184,000
Principal payments of debt		(189	)		(121,926	)
Payments of debt issuance costs		(720	)		(6,456	)
Collateral for letters of credit		—			(5,439	)
Net cash provided by financing activities		61,091			50,179

NET (DECREASE) INCREASE IN CASH AND CASH EQUIVALENTS		(9,361	)		5,399
Cash and cash equivalents – beginning of period		41,626			47,917
CASH AND CASH EQUIVALENTS – END OF PERIOD	$	32,264		$	53,315

Non-GAAP Financial Summary	Three Months Ended
(in thousands)	Sep 30, 2021			Dec 31, 2021			Mar 31, 2022			Jun 30, 2022			Sep 30, 2022			Dec 31, 022			Mar 31, 2023			Jun 30, 2023			Sep 30, 2023
Medicare risk-based revenue	$	76,428		$	91,277		$	107,747		$	143,664		$	122,267		$	113,041		$	121,593		$	155,486		$	134,105
Medicaid risk-based revenue		20,884			20,160			20,165			19,896			19,852			36,620			25,626			30,054			23,950
Government value-based care revenue		—			—			—			—			—			—			10,010			22,206			28,067
Other revenue		7,308			6,869			9,008			8,719			15,551			14,602			15,754			16,694			15,721
Total revenue		104,620			118,306			136,920			172,279			157,670			164,263			172,983			224,440			201,843

External provider costs		73,329			79,724			92,856			120,348			106,900			104,078			110,673			156,995			139,139
Cost of care		20,315			22,606			26,854			30,293			30,150			34,581			37,627			38,865			41,599
Platform contribution		10,976			15,977			17,210			21,638			20,620			25,604			24,683			28,580			21,106
Platform contribution margin (%)		10.5	%		13.5	%		12.6	%		12.6	%		13.1	%		15.6	%		14.3	%		12.7	%		10.5	%

Sales and marketing		1,274			2,615			3,301			2,299			2,355			3,806			3,765			3,381			3,501
Corporate, general and administrative		9,715			11,228			10,873			12,165			13,877			17,263			21,329			18,158			15,527
Adjusted operating expenses		10,988			13,843			14,174			14,464			16,232			21,069			25,094			21,539			19,028

Adjusted EBITDA	$	(13	)	$	2,134		$	3,035		$	7,175		$	4,388		$	4,535		$	(411	)	$	7,042		$	2,077

Reconciliation to Adjusted EBITDA	Three Months Ended
(in thousands)	Sep 30, 2021			Dec 31, 2021			Mar 31, 2022			Jun 30, 2022			Sep 30, 2022			Dec 31, 2022			Mar 31, 2023			Jun 30, 2023			Sep 30, 2023
Net Income (loss)	$	(14,479	)	$	(3,553	)	$	(16,797	)	$	(9,381	)	$	(22,053	)	$	10,434		$	(82,082	)	$	(32,376	)	$	(103,123	)
Interest expense		1,291			1,905			1,728			3,896			6,076			8,542			10,711			13,197			14,000
Depreciation and amortization		5,176			6,089			5,062			4,903			4,573			7,180			6,576			6,828			6,833
Remeasurement of warrant and contingent earnout liabilities		1,398			(8,734	)		3,536			(7,391	)		7,331			(84,171	)		(37,242	)		15,786			(1,450	)
Goodwill impairment		—			—			—			—			—			70,000			98,000			—			80,000
Stock-based compensation		966			375			1,087			2,788			3,611			2,786			2,298			2,464			3,243
Loss (gain) on extinguishment of debt, net		(279	)		7			—			6,172			—			—			—			—			—
Business Combination integration costs ⁽¹⁾		3,176			2,277			4,379			1,887			2,586			163			716			686			483
Acquisition and integration related costs⁽²⁾		1,871			2,325			3,429			4,074			2,118			10,632			622			815			652
DeSpac costs		27			742			9			10			11			10			—			—			—
Other⁽³⁾		840			543			421			46			(46	)		(967	)		(187	)		(535	)		1,263
Income tax provision (benefit)		—			159			181			171			181			(20,074	)		177			177			177
Adjusted EBITDA	$	(13	)	$	2,134		$	3,035		$	7,175		$	4,388		$	4,535		$	(411	)	$	7,042		$	2,077

Memo:
De novo pre-opening costs	$	544		$	806		$	973		$	506		$	2,426		$	3,205		$	1,975		$	1,560		$	1,880
De novo post-opening costs		195			489			1,119			993			1,533			2,274			3,885			4,228			3,906

(1)

Represents initial costs to set up public company processes, incremental vendor expenses identified as temporary or duplicative and expected to be rationalized in the short term, and legal and professional expenses outside of the ordinary course of business, which are being incurred as part of the Company’s efforts as it integrates the two privately held companies that were combined in the Business Combination. Significant components of Business Combination integration costs were as follows:

	Three Months Ended
(in thousands)	Sep 30, 2021		Dec 31, 2021			Mar 31, 2022		Jun 30, 2022		Sep 30, 2022		Dec 31, 2022			Mar 31, 2023		Jun 30, 2023		Sep 30, 2023
Consulting and legal fees (a)	$	2,204	$	1,639		$	3,190	$	887	$	725	$	257		$	282	$	237	$	69
Severance costs		—		949			25		252		1,080		167			11		13		—
Other (b)		972		(311	)		1,164		748		782		(261	)		423		436		414
	$	3,176	$	2,277		$	4,379	$	1,887	$	2,586	$	163		$	716	$	686	$	483

	(a) Represents consulting and legal costs directly associated with efforts related to integration of the two privately held companies that were combined in the Business Combination.
	(b) Represents primarily vendor expenses identified as temporary or duplicative and/or expenses outside the ordinary course of business and not necessary to run the Company’s business.

(2)	Includes all costs recognized in acquisition related costs in our condensed consolidated statements of operations and incremental payroll compensation expense for employees directly associated with services to achieve synergies related to closed transactions. Significant components of acquisition and integration related costs were as follows:

	Three Months Ended
(in thousands)	Sep 30, 2021		Dec 31, 2021		Mar 31, 2022		Jun 30, 2022		Sep 30, 2022		Dec 31, 2022		Mar 31, 2023			Jun 30, 2023			Sep 30, 2023
Advisor and other professional fees (a)	$	1,183	$	1,183	$	1,622	$	2,359	$	1,219	$	9,877	$	(258	)	$	(34	)	$	94
Compensation costs (b)		688		1,142		1,808		1,715		899		755		880			849			558
	$	1,871	$	2,325	$	3,429	$	4,074	$	2,118	$	10,632	$	622		$	815		$	652

	(a) Includes payments to our third-party transaction advisory firm associated with transaction contracts, including the Steward transaction that closed in November 2022. Also, costs include legal and accounting fees directly associated with contemplated or closed transactions.
	(b) Includes incremental payroll compensation expense for employees directly associated with services to achieve synergies related to closed transactions.

(3)	Components of other were as follows:

	Three Months Ended
(in thousands)	Sep 30, 2021		Dec 31, 2021		Mar 31, 2022		Jun 30, 2022			Sep 30, 2022			Dec 31, 2022			Mar 31, 2023			Jun 30, 2023			Sep 30, 2023
Software sale	$	—	$	—	$	—	$	—		$	—		$	(1,000	)	$	—		$	—		$	—
Tax-related costs		266		95		265		69			(178	)		46			—			—			—
Legal settlement		75		229		—		(43	)		—			—			—			—			—
Interest income		—		—		—		—			—			—			(253	)		(602	)		(433	)
Severance costs		—		—		—		—			—			—			—			—			1,639
Other		499		219		156		19			133			(13	)		66			67			58
	$	840	$	543	$	421	$	46		$	(46	)	$	(967	)	$	(187	)	$	(535	)	$	1,263


Non-GAAP Operating Metrics	Sep 30, 2021			Dec 31, 2021			Mar 31, 2022			Jun 30, 2022			Sep 30, 2022			Dec 31, 2022			Mar 31, 2023			Jun 30, 2023			Sep 30, 2023
Centers		40			45			48			48			51			62			62			62			62
Markets		3			4			6			6			7			7			7			7			7
Patients (MCREM)*		40,400			50,100			50,600			54,000			57,400			221,500			225,100			226,500			228,700
Patients in value-based care arrangements (MCREM)		87.2	%		79.3	%		79.8	%		81.0	%		78.2	%		97.6	%		99.0	%		99.4	%		98.8	%
Platform Contribution ($, millions)	$	11.0		$	16.0		$	17.2		$	21.6		$	20.6		$	25.6		$	24.7		$	28.6		$	21.1
* MCREM defined as Medicare Equivalent Members, which assumes the level of support received by a Medicare patient is equivalent to that received by three Medicaid or Commercial patients.

Reconciliation to Platform Contribution

	Three Months Ended
(in millions)	Sep 30, 2021		Dec 31, 2021		Mar 31, 2022		Jun 30, 2022		Sep 30, 2022		Dec 31, 2022		Mar 31, 2023		Jun 30, 2023		Sep 30, 2023
Gross profit (a)	$	4.5	$	9.6	$	11.2	$	15.4	$	14.8	$	17.2	$	17.1	$	20.4	$	12.0
Depreciation and amortization		5.2		6.1		5.1		4.9		4.6		7.2		6.6		6.8		6.8
Stock-based compensation		—		0.1		0.4		1.3		1.2		1.2		1.0		1.3		1.2
Other adjustments (b)		1.3		0.2		0.5		0.1		0.1		—		—		—		1.0
Platform Contribution	$	11.0	$	16.0	$	17.2	$	21.6	$	20.6	$	25.6	$	24.7	$	28.6	$	21.1

(a) Gross profit reflects the reclassification of stock-based compensation expense previously included in corporate, general and administrative expenses, which decreased gross profit by $0.1 million during the three months ended December 31, 2021, $0.4 million during the three months ended March 31, 2022, $1.3 million during the three months ended June 30, 2022, $1.2 million during the three months ended September 30, 2022, and $1.2 million during the three months ended December 31, 2022.
(b) Other adjustments include incremental costs related to post-Business Combination integration initiatives and other one-time center-level costs. Other adjustments reflected during the three months ended September 30, 2021 include $0.6 million of incremental costs relating to one-time operational projects and $0.3 million of non-cash true-up of deferred rent expense. Other adjustments reflected during the three months ended March 31, 2022 include $0.3 million of costs for a pilot project regarding outsourcing and during the three months ended September 30, 2023 include $1.0 million of severance costs related to center staff.

Calculation of the Medical Expense Ratio

	Three Months Ended September 30,						Nine Months Ended September 30,
(in thousands, except ratio)	2023			2022			2023			2022
External provider costs	$	139,139		$	106,900		$	406,807		$	320,104
Medicare and Medicaid risk-based revenue		158,055			142,119			490,814			433,591
Medical Expense Ratio		88.0	%		75.2	%		82.9	%		73.8	%

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