HMO Reinsurance

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Our customers enjoy distinctive and personal attention to assist them in all personal and commercial lines of insurance needs. Our level of administration efficiency in underwriting and actuarial support permits us to pass on the savings to our clients in the form of lower than average premiums.

REQUEST FOR PROPOSAL

HMO REINSURANCE QUESTIONNAIRE

After completing the form below press or

Name of HMO:

Street Address:

City: State: Zip:

Mailing Address (if different from above):

Telephone Number: Fax

Chief Executive Officer:

Chief Financial Officer:

Medical Director:

Marketing Director

CONTACT PERSON:

Name: Title:

Date Submitted:

Date Proposal Needed:

Effective Date of Reinsurance:

GENERAL QUESTIONS:

1. Type of HMO: Group Staff IPA Network

2. HMO is: For Profit Not for Profit

3. Primary ownership of HMO:

4. Expected enrollment in 12 months:

5. Is Medicare to be covered by Reinsurance? Yes No

6. Does this HMO have Professional Liability? Yes No

a. Insurance Carrier:

b. Limits of Liability:

c. Expiration Date:

7. Does this HMO have Directors and Officers Liability? Yes No

a. Insurance Carrier:

b. Limits of Liability:

c. Expiration Date:

CURRENT REINSURANCE TERMS:

1. Name of Carrier:

2. Expiration Date of Coverage:

3. Renewal Premium Per Member Per Month:

4. Does the HMO have Professional Liability Yes No

5. Where do you provide the following tertiary care?

Premature Infants:

Cardiovascular Care:

Burns:

Organ Transplants:

Severe Trauma:

6. List tertiary services which are capitated.

ADDITIONAL DOCUMENTS TO ACCOMPANY THIS QUOTE REQUEST
( Please fax these to (305) 598-9806 )

1. Copy of current Reinsurance Policy.

2. Copy of HMO Benefit Plan to members.

3. Specimen copy of hospital agreement (and physician agreement, if applicable).

If there are per diems, capitation and/or discounted arrangements, provide a

copy of the reimbursement arrangement of each.

4. Copy of the latest audited Financial Statement, latest available unaudited interim

financial statement, and latest quarterly NAIC Report.

All the above copies can be emailed to hmoreinsirance@mcicgroup.com or sent by fax to (305) 598-9806

5. List of past three (3) years claims experience for all members whose charges

exceeded the deductible. Include:

� Dates of service

� Date of birth (or similar identification)

� Reason for hospitalization (Diagnosis)

� Hospital

� Payment basis, e.g., DRG, per diem, FFS, etc.

� Total amount of hospital bills related to the above hospital days

� If physician coverage is included, total amount of physician charges

� Amount recovered from reinsurance

6. Listing of all current members presently under treatment whose total expenses

are expected to exceed the deductible before the end of this contract period.

Include the following:

� Dates of service

� Hospital

� Prognosis

� Expenses incurred to date

� Expenses expected to be incurred

� Listing of all current members who are potential reinsurance claims for

the upcoming contract period

List Below:

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