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Medical Captives FAQs

Affordable Health Benefits for
Small to Mid-Size Businesses

Glossary

Stop Loss Coverage that limits the amount the Employer pays on specific claims below the specific deductible. The Aggregate Excess Loss Coverage begins when the Employer’s claims under the specific deductible exceed the Aggregate Attachment Point.

The dollar amount at which Aggregate Stop Loss Coverage begins. The Employer’s Aggregate Attachment Point is the maximum amount the Employer will pay on all specific claims below the Specific Deductible.

The point at which the reinsurer’s aggregate coverage of the captive begins. The Captive Aggregate Attachment Point is equal to the captive premium plus the Collateral/Reserves of all Employers participating in the captive.

The Employer’s contribution to the captive’s asset pool, as security to ensure that sufficient assets are available to satisfy captive liabilities. Collateral/Reserves that are not needed to pay claims in the captive’s layer of risk are returned to the participants after the close of the underwriting year or credited to the next year.

An insurance facility for unrelated participants who join together to share risk. Each participant has a desire to better control and manage their risk. Participants typically deploy effective risk management programs.

A PBM administers prescription drug benefits. They work with prescription drug manufacturers, pharmacies, and drug wholesalers to help the Employer and employees access prescribed medication per their contract price. Their objective is to help members achieve the best possible outcomes, and the right PBM partner will also reduce pharmacy spend. More on PBMs can be found here.

Per enrolled employee per month.

Per enrolled employee per year.

A healthcare cost containment model that limits what a group health plan will pay for certain high-cost services (including hospital and outpatient facility charges), using Medicare reimbursement levels as a pricing model.

A group captive program that offers Medical Stop Loss coverage to middle market employers. An A.M. Best “A+” rated, class XV carrier issues the stop loss policies and Roundstone Management, Ltd. is the underwriter.

The amount the Employer pays on a specific (individual) claim before Specific Stop Loss Coverage begins.

Stop Loss Coverage that limits the amount the Employer pays on a specific claim. The Specific Stop Loss Coverage begins at the Employer’s Specific Deductible.

The practice of medicine using technology to deliver care at a distance. A physician in one location uses a telecommunications infrastructure (telephone, mobile app, website, video call) to deliver care to a patient at a different location. More on telemedicine can be found here.

A firm that handles certain administrative responsibilities for the plan on a fee-for-service basis, as contracted by the Employer. These responsibilities generally include drafting plan documents, processing and paying medical service provider invoices, and submitting stop loss claims.