Risk Protection Reinsurance for High Cost Cases. The Contractor must have a risk protection arrangement during the term of this Agreement. This risk protection arrangement must include reinsurance that covers, at a minimum, 80% of inpatient costs incurred by one (1) Member in one (1) year in excess of $150,000. The Department may alter or waive the reinsurance requirement if the Contractor proposes an alternative risk protection arrangement that the Department determines is acceptable. The Contractor may not change or discontinue the risk protection arrangement without advance written approval from the Department, which approval shall not be unreasonably withheld. The Contractor 100 must notify the Department thirty (30) days prior to any change in the risk protection arrangement. The Department reserves the right to review such risk protection arrangements and require changes based on the Department's assessment of the Contractor's overall financial condition. The reinsurance threshold requirement shall be $75,000, instead of $150,000, if any of the following criteria is met:
Risk Protection Reinsurance for High Cost Cases. The Contractor must have a risk protection arrangement during the term of this Agreement. This risk protection arrangement must include reinsurance that covers, at a minimum, eighty (80) percent of Inpatient costs incurred by one (1) Member in one (1) year in excess of $150,000. The Department may alter or waive the reinsurance requirement if the Contractor proposes an alternative risk protection arrangement that the Department determines is acceptable. The Contractor may not change or discontinue the risk protection arrangement without advance written approval from the Department, which approval shall not be unreasonably withheld. The Contractor must notify the Department thirty (30) days prior to any change in the risk protection arrangement. The Department reserves the right to review such risk protection arrangements and require changes based on the Department's assessment of the Contractor's overall financial condition. The reinsurance threshold requirement shall be $75,000, instead of $150,000, if any of the following criteria is met:
Risk Protection Reinsurance for High Cost Cases. If the PH-MCO is eligible for inclusion in the High Cost Risk Pool, for every HealthChoices Zone of operation, per Appendix 3k, then risk protection reinsurance is not required. Reinsurance is also not required if the PH-MCO has, at a minimum, a combined membership of 60,000 Members across all Pennsylvania lines of business.
