MCO Reinsurance Application

MCO Name

Date

Address

Years in business

Counties Served

Total Lives at risk now under capitation

Total # HMO's

Total lives at risk under proposed new risk contract(s)

Total IPA's

Number of members for each population:

Medicare			ED
Medicaid			ED
Commercial			ED
Other			ED

Type of risk being taken by HMO / MCO: (check appropriate blanks)
All (Global) risk	Pharmacy
Hospital charges in-area	Home Health/ SKF
Hospital charges out of area	Hem/Onc
Primary Care Professional	Psych
Specialty Care Professional	DME
Professional charges out of area	Transplants
Other

Please check desired Professional and Hospital deductibles

(if pure per diem policy reimbursement desired, so indicate in "B")

A) Co Insurance / Deductibles (C=Commercial, M=Medicare, D=Medicaid)

Co Insurance

Physician/Hospital

80%

90%

Deductibles

Physician

Hospital

$7,500

$10,000

$15,000

$20,000

Other

$30,000	$75,000
$40,000	$100,000
$50,000	$150,000
$60,000
Other

B) Per Diem(s)

(Claims Reimbursement @ 100% co ins.)

Option 1
ACU	ICU/CCU/NICU
$700	$1000
$800	$1,100
$900	$1,350
Other

Option 2

$ /D in area

$ /D OOA

Tplants incl

State Desired Coverage:

Claims Basis: Incurred in 12 months, paid in 18 months basis.

Fee schedule reimbursement at RBRVS and/or Medicare allowable? Yes No

Other - Claims Bases

Accrued at %

Please provide aggregate coverage at % of budget with a 90% co insurance. Yes No

If yes, please attach 3 years claims data by month: i.e. Total claims PAID and # lives covered in each month. Also include actuarial cost/capitation reports.

Please provide:

Insolvency coverage: Yes No

Conversion Coverage: Yes No

Inner Aggregate option: Yes No

Copy of current stop-loss Policy: Name: Years:

Please provide Name(s) of HMO's/EPO's/PHO's being contracted with (if applicable)
Name	# of years	E.D.

Utilization and Control Techniques:

Do you have a full time Medical Director? Yes No

Number of FTE doing QA/UR/UM

Please provide program description for UM.

Name of current Utilization Management software

Name of National PPO Network Provider

Contact Information & Comments

Contact Name
Title
Contact Number

Additional Comments

Please be prepared to provide:

Summary of hospital per diem agreements for in network ACU, ICU, CCU, NICU, Burn, Tplant
Reinsurance Recovery Report past two years (if applicable)
All current claims in excess of 50% of current attachments.
Days per 1000 for Medicare, Medicaid, Commercial populations Ave. inpatient charge per day (if available)
Audited Financials of HMO (Income statement past 1- 3 years)
Audited Financials of Hospital System backing owned HMO
Prognosis and Diagnosis of any currently hospitalized patients or members expected to exceed 50% of retention.
Broker of record letter authorizing Provider Risk, Inc., Broker of record
Census (Age/ sex delineated for current book)
Summary Benefit Sheet(s) or Member hand books (Please include 4 copies)
Actuarial Analysis (if available)
Decription of National PPO network contract inclusive of Transplant, NICU, pharmacy, Burn, cardiac, cancer, rehab if it exist. (i.e. Case rates or perdiem contracts)