Section R9-22-720. Reinsurance

A.      Reinsurance is a stop-loss program provided by the Adminis- tration to a contractor for partial reimbursement of the cost of covered services for a member with an acute medical condi- tion when the cost of covered services exceeds a pre-deter- mined deductible level amount within a contract year. The Administration self-insures the reinsurance program through a reduction to capitation rates. The reinsurance program also includes a catastrophic reinsurance program for members diagnosed with specific medical conditions.

B.       The Administration shall specify in contract guidelines for claims submission, processing, payment, and the types of care and services that are provided to a member whose care is cov- ered by reinsurance.

C.      When the Administration determines that a contractor does not follow the specified guidelines for care or services and the care or services could have been provided at a lower cost according to the guidelines, the Administration shall reimburse the con- tractor as if the care or services had been provided as specified in the guidelines.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 3317, effective July 15, 2002 (Supp. 02-3). Amended by final

rulemaking at 13 A.A.R. 856, effective May 5, 2007

(Supp. 07-1).