Medical Excess

Medical Excess

When claim costs spiral out of control, you need to be prepared. We have over 30 years experience managing catastrophic medical risk. See below for our programs:

CME’s transplant carve-out program is a powerful tool to manage specialized risk. The program provides expert knowledge as well as risk-transfer which is customized to this area of medicine. Transplants and all related claims are covered from 10 days prior to 365 days following the covered procedure. Experience and long-standing relationships within the transplant specialty enhance the program’s effectiveness in managing claims and providing service to your members.

These programs can be a very effective tool to manage transplant risk. This is increasingly important as the number of transplants performed are on the rise, making experienced management ever more critical.

Fully Insured Program:

  • Solid organ and bone marrow procedures covered
  • Known cost for unknown catastrophic liability
  • Travel expenses and second opinions covered
  • Rating based on transplant claims experience for MCOs
  • Pooled rate for self-insured ERISA plans
  • Reduced reinsurance and stop loss rates for MCOs and ERISA Plans
  • Contract negotiating enhancement

Transplant Network

  • Finest network available
  • Outstanding contracted rates
  • Top survival rate from providing Transplant “Centers of Excellence”
  • Case management included

Self-insured employers, third party administrators and ASOs have to continually evaluate the stop loss coverage they have selected for their plans or clients. The key points to consider are access, quality and cost efficiency. We do more than simply try to cap catastrophic claims; we try to determine if these risks are more appropriately transferred to providers. We currently offer transplant, disease management, neonatal, burn, and AIDS programs (tertiary). Our options are tailored to the changing climate and individual needs.

Specific:

  • Deductible set to take advantage of good claims history.
  • Profit commission when you have a good year with a small number of catastrophic illnesses.
  • Limits of liability up to $2 million per member per year.
  • Excellent turnaround on claims reimbursement.

Aggregate:

  • Plan rated on your experience.
  • Attachment point to assure plan stability.
  • Both run-in/paid and incurred coverage are offered.

Value Added:

  • Organ and transplant programs.
  • Drop-down deductible transplant endorsements.
  • Moving from fully insured to self-insured.
  • Having the tools necessary to remove most of the uncertainty in changing your health plan.

The healthcare industry is making major adjustments and restructuring though the ACA. The accountability, improved health outcomes and lower cost are huge undertakings if done one at a time. Now, you as a provider must take on all three plus carry risk with numerous contracted risk-sharing programs. These new arrangements are similar to their forerunners such as the integrated delivery systems (IDS), independent practice associations (IPA), and the provider health organizations (PHO) of years ago.

With 30+ years’ experience, Catastrophic Medical Excess (CME) has the experience and relationships to work with you to establish the appropriate excess program(s). Now we have the Accountable Care Organizations (ACO’s), Bundled Payments (BPCI), Medicare Shared Savings Programs for ACO’s and the list of programs goes on. In Alabama, Medicaid is setting up Regional Care Organization (RCO’s) and in the State of Oregon there are Coordinated Care Organization (CCO’s)

Whether it is Medicare, Medicaid, SCHIP, Commercial or carve-out, financial integrity must be retained to assure vibrant operations and outstanding care for your patients. As a provider, you know the absolute best way to lower cost is through healthy and happy patients. Plus, global cap is coming in 2018!

Full Capitation

Risk Sharing

ACOs

HMO Panels

Medicaid RCOs

Co-Ops

And whatever is next…..

Virtually every state’s Department of Insurance has mandated health maintenance organization reinsurance. The HMO policy must include not only stop loss coverage, but also continuation of plan benefits (insolvency) and, in most states, a conversion plan. Our reinsurance underwriters offer far more value added enhancements, such as transplant and NICU networks where ADMs are waived. We can tailor your coverage to take care of all these requirements plus the specifics you’ve put in place to make yourself competitive.

  • NICU Carve-out programs
  • Custom-designed programs
  • Incentives for good management and claims history
  • Capped risk for any one claim
  • Continuation of benefits coverage (insolvency)
  • Conversion coverage, where required, for coverage when members move out of the area or insolvency occurs without evidence of insurability
  • Access to Transplant Centers of Excellence

The target for this product is the correctional market, which consists of state prisons, county and local jails as well as federal correctional facilities. A prison is a facility in which the inmate is incarcerated for an extended period of time (typically one year or longer). A jail is a facility in which the inmate is held for a shorter period of time, often awaiting trial or sentencing. The higher inmate turnover in jails requires that healthcare be provided to a much larger number of individual inmates over time but for short duration. Due to the high number of inmate with one or more chronic diseases the potential for hospitalization is high.

We believe this is a niche market that is currently under served in the insurance market place today. This product will help state, county and local governments smooth the variances in their budgets by removing their high cost claims. Private management companies will also benefit from using this product when they are in a risk taking position.

Features/Benefits

  • Budgeting takes the unexpected catastrophic claim out of the equation.
  • Cost takes part of the sting out of increasing medical inflation, especially as it relates to tertiary care.
  • Planning goes hand in hand with the budgeting process and maintains program consistencies with fewer surprises.
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