Managed Care Underwriting Guidelines

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HMO Reinsurance Underwriting Parameters

Hospital / Facility Coverage 
Minimum Deductibles: 
Commercial75,000
Medicare75,000
Medicaid75,000
Coverage Limits: 
Maximum Coinsurance0.9
Maximum ADM (Average Daily Maximum)varies based upon deductible and coverage structure
Maximum Limit$2,000,000 per member per contract period
Maximum Policy PeriodTwelve Months
Standard Run-Out PeriodIncurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)
Maximum ReimbursementLesser of contracted amount, ADM times length of stay, paid amount, or billed amount.

 

Physician / Professional Coverage 
Minimum Deductibles: 
Commercial15,000
Medicare15,000
Medicaid15,000
Coverage Limits: 
Maximum Coinsurance0.9
Maximum Reimbursement150% of RBRVS (will consider alternate on case-by-case basis)
Maximum Limit$1,000,000 per member per policy period
Maximum Policy PeriodTwelve Months
Standard Run-Out PeriodIncurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)

 

Provider Excess of Loss Insurance Underwriting Parameters

Hospital / Facility Coverage 
Minimum Deductibles: 
Commercial50,000
Medicare50,000
Medicaid50,000
Coverage Limits: 
Maximum Coinsurance0.9
Maximum ADM (Average Daily Maximum)varies based upon deductible and coverage structure
Maximum Limit$1,000,000 per member per contract period
Maximum Policy PeriodTwelve Months
Standard Run-Out PeriodIncurred in 12 Months
Paid in 18 months, Reported in 19 months (may be extended on case-by-case basis)
Maximum ReimbursementLesser of % of Billed Charges or ADM times length of stay. Medicaid limited to Medicaid DRG's for specified area.
Minimum Premium$50,000 per policy period

 

Physician / Professional Coverage 
Minimum Deductibles: 
Commercial15000
Medicare15000
Medicaid15000
Coverage Limits: 
Maximum Coinsurance0.9
Maximum Reimbursement150% of RBRVS (will consider alternate on case-by-case basis)
Maximum Limit$1,000,000 per member per policy period
Maximum Policy PeriodTwelve Months
Standard Run-Out PeriodIncurred 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