Your organization deserves a partner that understands the balance between cost control and quality care. Our Managed Care Products are designed to do just that—streamline processes, enhance recovery, and protect your bottom line. These FAQs answer common questions and show how we can help you succeed.
Managed Care Reinsurance is coverage purchased by health plans, HMOs, IPAs, or RBOs to protect against unexpectedly high medical costs. It reimburses the organization when claims exceed certain thresholds, stabilizing financial performance and allowing more predictable budgeting.
HMO Reinsurance is purchased by a licensed health plan or HMO to protect against catastrophic medical expenses. Structures include Specific Excess of Loss, Aggregate Excess of Loss, and specialty carve-outs such as NICU and transplant.
Provider Excess protects provider groups that take capitation risk. HMO Reinsurance protects the health plan itself. Provider Excess is built around managing capitated medical risk at the IPA/RBO level.
Global Coverage applies when an entity assumes both professional (provider) and institutional (hospital) risk under a single capitated or delegated agreement. Under this structure, both categories of medical cost roll up toward one combined deductible under the stop-loss policy.
Instead of having separate deductibles for professional and institutional claims, all eligible claim costs accumulate together. This is common for large medical groups, integrated systems, or RBOs managing comprehensive risk. It increases exposure but allows broader protection under one attachment point.
– IPAs contracted under full-risk arrangements.
– Medical groups delegated inpatient, outpatient, ancillary, and professional services.
– Groups managing Medicare, Medi-Cal, or D-SNP populations under global capitation.
– Simplifies risk protection by combining exposure categories.
– Reduces administrative complexity related to claim sorting.
– Provides strong protection for groups with high-acuity or institutional-heavy populations.
– Offers stable underwriting and solvency planning.
– Higher volatility because institutional claims can spike quickly.
– Deductibles must reflect combined exposure, not just professional risk.
– Carriers may require more detailed financial reporting and oversight.
An RBO is an entity that assumes global or professional financial risk under a contract with a health plan. In California, RBOs are regulated by the Department of Managed Health Care (DMHC) and must meet solvency standards.
It is not always legally required, but it is strongly recommended and often required by contracted health plans. Stop-loss protects RBOs from catastrophic losses and supports solvency compliance.
No. Being listed is not a prerequisite for purchasing stop-loss. Carriers may request more information for underwriting if the group is not registered.
The Knox-Keene Act regulates health care service plans in California. It includes licensing, solvency requirements, network adequacy rules, and oversight of RBO reporting.
No. Being listed is not a prerequisite for purchasing stop-loss. Carriers may request more information for underwriting if the group is not registered.
No. Professional-only risk typically qualifies a group as an RBO but does not require a full Knox-Keene license unless the group takes on institutional risk or operates as a health plan.
HMOs purchase HMO Reinsurance to stabilize premium and protect surplus. IPAs/RBOs purchase Provider Excess to protect against catastrophic medical costs under capitation.
Rising transplant and oncology severity, Gene & Cell Therapy, NICU volatility, Medi-Cal and D-SNP growth, increased solvency oversight, and consolidation among provider groups.
It provides capital relief, protects against catastrophic claims, stabilizes performance, and allows organizations to take on more membership or complex populations.
Common populations include Commercial HMO, Medicare Advantage, Medi-Cal, D-SNP, and high-acuity cohorts such as dialysis, transplant, and oncology.
Provider Excess: $25K–$100K. HMO Reinsurance: $200K–$500K+ or higher.
Carriers review membership data, capitation terms, historical claims, financials, solvency, and risk contracts. Pricing is tailored to risk pools and deductible levels.
Historical claims data and membership reports, capitation contracts, membership reports, financials, and current stop-loss policy.
Additionally, for HMO Reinsurance hospital contracts, IBNR reports, benefit designs, and network descriptions are helpful to have as well.