This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. A typical HMO excess coverage provides risk protection for all catastrophic events—traumas, transplants, neonatal cases, and other complex medical claims. Some plans, however, prefer to "carve out" certain risks from their medical excess coverage and have specific coverage for the given risk on a first dollar basis. Organ and bone marrow transplant carve-out coverage is such an example.
ABC Health Plan is a public hospital board authorized by statute to operate a hospital service plan in its state. Because the plan desired predictability and the plan's hospital owner is not a major tertiary provider for organ transplants (excluding kidneys), the plan was interested in having organ transplants carved out from its risk.
Summit Re provided ABC Health Plan an organ transplant carve-out through United HealthCare Insurance Company, part of OptumHealth Care Solutions’ (formerly United Resource Networks) family of transplant programs. Summit Re still provides the medical excess coverage to ABC Health Plan in excess of its $90,000 deductible with an appropriate credit for the organ transplant carve-out now reinsured by United.
ABC Health Plan has renewed the program for several years with predictable renewals and has access to excellent organ transplant case management and provider contracts. A typical premium for this type of coverage is $2.00-$4.00 per member per month, depending on the parameters of the risk.
Covered organ transplant procedures include liver, kidney, heart, lung, heart/lung, double lung, pancreas or simultaneous pancreas/kidney. Digestive transplants are covered only when performed by a facility that participates in the transplant network. Coinsurance is higher for services provided by non-network facilities.
Transplant services include all medically necessary services resulting from and/or directly related to an organ or bone marrow transplant procedure, including:
- Services provided by the transplant facility
- Hospital or skilled nursing facility services
- Physician services
- Nursing services
- Outpatient treatment and follow-up
- Speech, physical and occupational therapy
- Anesthesia and anesthesia services
- Laboratory services
- Durable medical equipment
- Blood and blood products
- Harvesting and acquisition expense
- Transportation, lodging and meals for transplant candidate and one companion
Typical services NOT covered include:
- Services received before or after the benefit period, other than services for bone marrow harvesting, transplant evaluation, living donor organ procurement, air ambulance or transportation, lodging or meals related to the covered transplant procedure
- Organ or tissue transplants performed prior to the member’s effective date
- Services not related to the covered transplant procedure
- Services unrelated to the diagnosis or treatment of the transplant procedure
- Drugs that are investigational or have not been approved for general sale by the FDA
- Items which are not medically necessary