How It Works

MediCaptive, a group captive health insurance company, has built a cost management structure that allows small and medium-sized professional services employers to assume a portion of their own healthcare risk and share it with similar, well-qualified employers. Assuming this risk allows businesses to access the following benefits:

Lower stop-loss insurance pricing, which protects employers from large claims

Substantially mitigated annual increases

Access to claims data to help manage medical and pharmaceutical health care expenses

Access to skilled professionals who can help control healthcare costs through wellness programming and provider management

Avoid unrecoverable premium costs

Maintain current plans and providers, minimizing disruption to business processes

Integrate seamlessly into business structure so employees can keep their doctors

MediCaptive breaks the total assumed healthcare risk into three layers: retained, shared and transferred. Breaking the total risk into layers gives employers more control over claims costs and allows risk to be shared between professional services businesses to achieve optimal pricing.  You enjoy the same advantages as Fortune 100 companies.


Employers retain a portion of each employee claim submitted to the plan. The amount is flexible. Retaining a portion of each claim provides employers with control, through claims data access, to better manage the costs of healthcare through wellness programs and managed care.


Employers share claims that exceed the retained portion with other employers in the group captive arrangement.


Large and catastrophic claims, beyond the retained and shared layers, are assumed by Swiss Re – a large third-party underwriter of medical and stop-loss insurance and MediCaptive’s preferred provider.

Claims Management Programs

Employers can also reduce insurance costs through claims management. Reduced claims translate into reduced costs when you assume health care risk. It also significantly reduces stop-loss insurance rates at renewal time. Claims management is a function of two complementary components:

1. Risk prevention and 2. Risk mitigation.

This is the key to the employer group captive, and it is all driven by the data that becomes available to employers when they enter the MediCaptive program.

Healthcare Cost Formula


Risk prevention

Unit Cost

Risk mitigation

Risk prevention

Risk prevention is driven by the health of your employees. It is a function of claims data analysis correlated with the biometric data of your insured employees. Linking these two data sources allows employers to develop coaching and wellness programs, which incentivize employees to become healthy and stay healthy. Ultimately, this helps to reduce employers’ health care costs.

What is Population Health?

With Population Health, a group, in combination with their healthcare provider, can gather their population’s biometric data, connect it with medical and pharmacy claims, and analyze how actions such as health coaching and wellness resources are impacting their medical costs. Linking biometric data to current and past claims helps groups to forecast costs accurately and find actionable cost-saving solutions.

Data Analysis: Population Health translates into fewer high-cost claims. MediCaptive’s analytics team, in conjunction with your health care provider, will identify three important risk categories among your employee population: 1. Low risk, 2. Moderate risk and 3. High risk. Then a process is implemented to ensure that low-risk employees don’t trend upward, and those already at risk are well-managed.

Risk mitigation

Risk mitigation is the process that manages costs. Most health care spending is comprised of two elements: 1. Facility claims and 2. Specialty pharmacy.

Bundling: By paying cash for services at the time they are rendered and bundling physician, facility, anesthesia, pre-operative, and post-operative services, costs are dramatically reduced. Members are incentivized to participate in the program by eliminating deductibles and cost-sharing.

Specialty pharmacy: Patient assistance programs, which subsidize the costs of certain medications by the manufacturer, co-pays, or other programs, can dramatically reduce plan spending. Currently, 200+ drugs qualify for patient assistance programs.