Captivating
The ParetoHealth captives are chartered in this State?
What is Tennessee?
This document alignment exercise is designed to ensure that the plan as adjudicated by the TPA matches the way the stop loss carrier will evaluate reimbursement.
What is plan mirroring?
A plan has a $50,000 specific deductible and paid claims of $112,000, $85,000, and $170,000 for three people. This is the specific reimbursement:
What is $217,000
A carrier projects $2,000,000 of expected claims and applies a 25 percent corridor. This dollar amount is added before aggregate reimbursement begins.
What is $500,000?
This imaging-and-surgery solution uses pre-negotiated, direct episode prices, contingent on providers being paid in full before care is delivered.
What is Valenz Health?
ParetoHealth's has which stop loss carrier partners?
Who are Tokio Marine HCC, SunLife and SwissRe
This organization administers a self funded health plan but is not the stop loss carrier that reimburses eligible catastrophic losses.
What is a TPA?
A claimant has a $150,000 laser and $200,000 in paid claims. This is the carrier reimbursement, assuming the laser replaces the ordinary $50,000 specific deductible for that claimant.
What is $50,000?
Using the same $2,000,000 projection and 25 percent corridor, this is the aggregate attachment point.
What is $2,500,000?
This oncology program coordinates second opinions, evidence-based treatment protocols, and access to Cancer Centers of Excellence.
What is CancerCare?
ParetoHealth was started in what year?
What is 2012?
This underwriting term raises the claimant-specific threshold above the ordinary specific deductible because a known high-cost condition is expected.
What is a laser?
A member has a $500,000 conditional laser related to transplant, a $75,000 specific deductible, and $156,000 of eligible claims before a transplant(not related to transplant). This is the stop loss reimbursement at that point.
What is $81,000?
This is what an aggregate corridor creates above expected claims before aggregate stop loss coverage attaches.
What is margin or a buffer?
This included care-navigation model provides a benefits wallet, provider search with quality scores, and in-app/phone support at $0 PEPM.
What is Rightway select?
This risk-financing structure lets separately self insured employers participate in a shared risk pool while maintaining their own plan designs.
What is a captive?
Within a captive, these remain customizable for each employer even though risk is shared across the group.
What are plan design and benefits?
When a $250,000 laser is offered on a plan with a $50,000 specific deductible, this is the approximate upper bound for a premium alternative that removes the laser.
What is less than $250,000
This provision allows for monthly reimbursement of small claims rather than waiting till end of the plan year.
What is aggregate accommodation?
This pharmacy program sends every specialty medication and any prescription costing more than $1,500 per month to ParetoHealth for a secondary review after PBM approval.
What is the PRxC prior-authorization review process?
This principle means captive funding is not a flat charge for every employer; contributions reflect the employer's own risk profile.
What is risk-based funding or rating?
This is the practical consequence when plan documents and stop loss contract provisions are not mirrored: a paid plan claim may not qualify for stop loss reimbursement.
What is a reimbursement gap?
A member has a $500,000 conditional laser related to transplant, a $75,000 specific deductible, and $156,000 of eligible claims before a transplant(not related to transplant).This amount counts towards the aggregate deductible?
What is $75,000?
This is the key reason an employer should not treat an accommodation payment as permanent claim funding until the plan year’s aggregate result is finalized.
What is the potential repayment obligation?
Although Medicare-eligible employees represent about 4% of covered lives, they drive this share of total healthcare costs, a gap SmartConnect is designed to address.
What is 9%?