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Managed Care

HMOs and Health Plans

HMO Reinsurance

HMO Reinsurance is used to protect a Health Maintenance Organization from catastrophic health care claims. Reinsurance programs can be designed at varying retentions and coinsurance levels based on the HMO’s risk appetite. If necessary to meet state regulatory requirements, Insolvency coverage (Continuation of Benefits) is also available from the reinsurance marketplace.  

Medical Excess Reinsurance

Medical Excess is reinsurance designed to protect insurance companies, and other risk-bearing entities that are not licensed HMOs, from catastrophic health care claims. As with HMO Reinsurance, Medical Excess programs can be designed at varying retentions, coinsurance and limits of liability.

Quota Share Reinsurance

Quota-Share Reinsurance allows an HMO or insurance company to cede a proportion of its risk to an unaffiliated reinsurer while at the same time reducing the amount of risk based capital that the HMO or insurance company needs in its business.  Quota Share Reinsurance can be “full risk” (where the reinsurer shares proportionately in the profits and losses of the business) or “capital motivated” (where the focus is on minimizing the cost of the risk based capital relief provided by the reinsurance).

Aggregate Stop Loss

Aggregate Stop Loss provides protection to the underlying entity for an unexpected variance in its overall loss ratio. This coverage can be purchased in addition to specific stop loss coverage and is typically less expensive than a quota share option. Additionally, the reinsurer only participates in the down side risk, so the reinsured retains all of their premiums.

Property & Casualty Coverage

Risk Strategies provides a full suite of Property & Casualty insurance products and services for HMOs and Health Plans including:

  • Professional & General Liability
  • Management Liability / Managed Care E&O
  • Cyber Risk
  • Property & Other Lines

Health Care Providers

Specific Stop Loss

Specific Stop Loss provides protection against catastrophic claims on individual members.  It is intended to protect against abnormal severity rather than abnormal frequency and is appropriate for any health care provider participating in one or more risk based contracts.  Specific Stop Loss is flexible in its design and can be structured to match the risk appetite of the health care provider.  It is also available for all populations including commercial, Medicare, and Medicaid.  It is also appropriate for a health care organization’s self-insured medical plan.

Aggregate Stop Loss

Aggregate Stop Loss provides protection to the underlying entity for an unexpected variance in its overall performance which is often driven by unanticipated frequency rather than severity.  This coverage is often purchased in addition to Specific Stop Loss coverage and can be placed over a single risk contract or multiple risk contracts.  

Bundled Payment Stop Loss

Bundled Payment Stop Loss provides protection for health care providers who have accepted risk under a bundled model.  Most often, this risk is through either a CMS program such as BPCI or through a commercial payor contract.  This coverage provides protection for any procedure that exceeds a defined percentage of the target amount. 

Property & Casualty Coverage

Risk Strategies provides a full suite of Property & Casualty insurance products and services for health care providers including:

  • Professional & General Liability
  • Management Liability / Managed Care E&O
  • Cyber Risk
  • Property & Other Lines

Accountable Care Organizations

Aggregate Stop Loss

Aggregate Stop Loss is appropriate for any ACO taking two-sided risk.  Coverage is structured to mimic the underlying risk with attachment points and deductibles defined as a percentage of the ACO’s benchmark.  Aggregate stop loss provides ACOs the ability to quantify their “worst case scenario” and can be structured to provide risk transfer at a level commensurate with their risk appetite. 

Per Member Stop Loss

Per Member or Specific Stop Loss is designed to protect against catastrophic claims on individual members.  It is recommended for ACO’s that can “opt-out” of the CMS stop-loss program or for ACO’s with commercial, Medicaid or other risk contracts.   Coverage is tailored to match the risk appetite of the ACO.  It offers a simple attachment point and coinsurance plan design unlike the CMS program.  

Surety Bonds

Surety Bonds are appropriate for any ACO required to provide CMS or other governmental entities with proof of a repayment mechanism.  Surety Bonds are a cost effective alternative to a Letter of Credit (LOC) and keep the ACO’s capital intact.  Surety Bonds do not require a UCC filing.

Property & Casualty Coverage

Risk Strategies provides a full suite of Property & Casualty insurance products and services for ACOs including:

  • Professional & General Liability
  • Management Liability / Managed Care E&O
  • Cyber Risk
  • Property & Other Lines

Claims Service Center

The Claims Service Center:

  • Serves as a direct liaison to the client’s reinsurer/insurer
  • Reviews claim submissions and notifications to ensure accuracy of data and to expedite reimbursement
  • Ensures that policy coverage terms are appropriately and correctly applied
  • Serves as the client’s intermediary with the underwriter to resolve pended or denied claim issues
  • Creates a “hassle-free” claim processing environment by fielding and answering reinsurer/insurer questions, thereby reducing the number of unnecessary calls to the client and saving valuable time
  • Tracks and checks payments to ensure accuracy and timeliness of payments
  • Provides executive level quarterly reports to track recoveries and assists the client in effectively managing its stop loss program
  • Provides timely reporting reminders to ensure filing deadlines are met
  • Serves as a central repository for all claim related activity between the client and the reinsurer/insurer
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