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HMO Reinsurance


HMO Reinsurance is coverage for Health Maintenance Organizations (HMOs) and other Managed Care Organizations that are licensed to accept global risk for the health care of their members.


The coverage is designed to financially protect the organization from unforeseen catastrophic claim costs that exceed a selected retention level. Policies are usually written on an individual member, per-year basis, which is often called “specific,” though some policies also include aggregate provisions, based on the claims experience of an entire group of patients.  Coverage can be designed with a variety options to meet the organization’s needs and risk tolerance.

Eligible services can include any combination of inpatient hospital, outpatient hospital, sub-acute, professional, ancillary, pharmaceutical, and organ transplant services.


Pinnacle’s marketing process is as follows:

  • Jointly develop a strategy with the client supportive of their goals and needs.

  • Pinnacle carefully reviews and analyzes prior year claims data, stop-loss policies, division of financial responsibility matrix documents, membership history, and carrier reimbursement worksheets. Then, we make our recommendations for the policy design or provide suggestions to improve the in-force coverage.

  • We then use our knowledge of the marketplace to identify those insurers that will best meet the client’s goals.

  • Pinnacle presents the renewal options with comparative data and a detailed analysis of the choices, including our recommendations.

A few key points that make Pinnacle a unique broker are as follows:

  • Claim Auditing Services. We can audit 1 to 3 years of claims data for billing and payment errors, duplicates, and trends in the data.

  • Claim Filing Services. Clients have the ability to send Pinnacle a “data dump” of all of their paid claims for the policy year and Pinnacle will prepare the proper submission to the carrier.

  • Pre-Carrier Claims Adjudication

  • Underwriting Expertise

  • Deductible Analysis

  • Pended Claim Tracking

  • Quarterly Reports and Division of Financial Responsibility Matrix Review

  • Full Transparency

  • Strong Relationships with Most Major A+ Rated Stop-Loss Carriers

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