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1999 CAS Seminar on Health and Managed Care Provider Excess Insurance Overview

1999 CAS Seminar on Health and Managed Care Provider Excess Insurance Overview. Presented By: Riggs Stephenson Aon Risk Services Franklin, Tn October 18, 1999. Definition/Description.

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1999 CAS Seminar on Health and Managed Care Provider Excess Insurance Overview

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  1. 1999 CAS Seminar on Health and Managed CareProvider Excess Insurance Overview Presented By: Riggs Stephenson Aon Risk Services Franklin, Tn October 18, 1999

  2. Definition/Description • Provider Excess Insurance protects capitated hospitals and physicians against the cost of individual catastrophic claims

  3. Premium Distribution in Typical Full Risk Model Employer $120 per enrollee 17% Reinsurance Administration Contracting UM/QA Marketing $4 6% $7.20 Administrative Direct/MedReins Profit HMO 5% $6.00 6% $7.20 11% $100 83% $10 - $12 Capitated PHO ER Facility Outpatient Surgery Other Outpatient Inpatient Services ER Professional Primary Physicians Referral Physicians

  4. COVERAGE SOURCES • Health Plan • Commercial Provider Excess Insurer

  5. SPECIFIC STOP LOSS • Per member, Per Policy Period • Protects against large, catastrophic, individual cases * Neonates * Burns * Transplants * Cardio * Traumas, etc.

  6. COVERAGE FEATURES • Deductible (per member per year) • Coinsurance (excess of deductible) • Limit of Liability • Maximum Allowable Charges • Covered Eligible Expenses • Hospital and/or Physician Expenses

  7. CLAIM ADJUDICATION

  8. UNDERWRITING ISSUES • Completed Questionnaire/Application • Utilization Management Issues • Claims Experience Availability • Projected Enrollment • Start-up Risk Contracts

  9. UNDERWRITING PROCESS • Start-Up Opportunity * No Claims Experience; Manual Rate • Large Membership (i.e.50,000 members, low deductible, etc.) * Claims Experience Available; Experience Rated • Smaller Opportunity * Claims Experience Available * Too Small for Experience Rating; Blended Rate

  10. Location Membership type Covered services List of services not provided In-Network Tertiary referral contracted rates Inpatient days/1,000 Excess experience Coverage Structure Average inpatient billed charge per day RISK VARIABLES

  11. TYPES OF MEMBERS • Commercial • Medicare • Medicaid

  12. OTHER STOP LOSS PROGRAMS • Aggregate Stop Loss • Carve Outs

  13. QUESTIONS?

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