Managed Care
HMO Reinsurance Underwriting Parameters
Hospital/Facility Coverage:
Minimum Deductibles:
Coverage Limits:
Maximum ADM (Average Daily Maximum)
varies based upon deductible and coverage structure
Maximum Limit
$2,000,000 per member per contract period
Standard Run-Out Period
Incurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)
Maximum Reimbursement
Lesser of contracted amount, ADM times length of stay, paid amount, or billed amount.
Physician/Professional Coverage:
Minimum Deductibles:
Coverage Limits:
Maximum Reimbursement
150% of RBRVS (will consider alternate on case-by-case basis)
Maximum Limit
$1,000,000 per member per policy period
Standard Run-Out Period
Incurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)
Can provide Out-of-Area Conversion (via Celtic Life) and Insolvency / Continuation of Benefits Coverage upon approval of Health Plan’s financial data (link to financial requirements).
PROVIDER EXCESS OF LOSS INSURANCE UNDERWRITING PARAMETERS
Hospital/Facility Coverage:
Minimum Deductibles:
Coverage Limits:
Maximum ADM (Average Daily Maximum)
varies based upon deductible and coverage structure
Maximum Limit
$1,000,000 per member per contract period
Standard Run-Out Period
Incurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)
Maximum Reimbursement
Lesser of % of Billed Charges or ADM times length of stay. Medicaid limited to Medicaid DRG’s for specified area.
Maximum Premium
$50,000 per policy period
Physician/Professional Coverage:
Coverage Limits:
Maximum Reimbursement
150% of RBRVS (will consider alternate on case-by-case basis)
Maximum Limit
$1,000,000 per member per policy period
Standard Run-Out Period
Incurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)
Minimum Premium
$50,000 per policy period
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