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Catastrophic and unexpected health care claims are on the rise. This increase in catastrophic claims is, in part, the result of medical and pharmaceutical advances, such as specialty drugs and cell and gene therapies, as well as medical price inflation. As a result, many employers with self-funded health plans are actively looking for ways to minimize their financial exposures to potentially catastrophic claims. A common strategy these employers have leveraged is purchasing stop-loss insurance.

This article provides a general overview of stop-loss insurance and outlines some considerations for employers to keep in mind when deciding whether to purchase this coverage.

What Is Stop-loss Insurance?

Generally speaking, stop-loss insurance helps self-funded employers protect themselves from higher-than-anticipated health claim payouts by limiting their exposure to employee medical claims that exceed a predetermined amount. In other words, such coverage can prevent abnormal claim frequency and severity from draining employers’ financial reserves.

Stop-loss insurance plays an important role in helping employers manage their health care costs and protecting against unexpected or catastrophic claims, as it sets a ceiling for the amount they pay in health claims. This coverage is not a form of medical insurance, but rather a policy employers can purchase to manage their financial risks.

How Does Stop-loss Insurance Work?

Under a stop-loss insurance policy, an employer’s claims liability is limited to a certain amount (also called an attachment point), therefore ensuring abnormal employee health claims do not drain the employer’s financial reserves. An employer can add stop-loss insurance to an existing plan or purchase it independently.

If an employer’s health claims exceed a predetermined amount, their insurer will usually reimburse them for all additional claims. For example, if an employer has a stop-loss insurance policy with an attachment point of $500,000, their insurer will typically begin providing reimbursement after the plan’s claims exceed $500,000. It’s worth noting that since stop-loss coverage only reimburses an employer for claims that exceed their policy’s attachment point, the employer is initially responsible for paying employee claims before they reach the established cost ceiling.

Types of Stop-loss Insurance

There are two types of stop-loss insurance: individual (or specific) and aggregate (or total claims). Understanding the difference between individual and aggregate stop-loss insurance can help self-funded employers evaluate and determine which coverage best meets their needs and reduces their financial exposures. Because health plan usage can be unpredictable, some employers choose to purchase both individual and aggregate stop-loss insurance to provide their organizations with maximum financial protection.

Individual Stop-loss Insurance

Individual stop-loss insurance limits an employer’s liability when an individual employee’s medical claims exceed the attachment point. As such, this coverage can protect employers against unexpectedly high claims from individual employees.

Aggregate Stop-loss Insurance

Aggregate stop-loss insurance can help safeguard employers from the total sum of health claims for an entire group of employees rather than any one individual. Under this coverage, an employer is usually reimbursed when their expenses for all employees’ medical claims exceed the attachment point for the plan year.

Stop-loss Insurance Considerations

Each organization is unique. Deciding whether stop-loss insurance is necessary depends on an organization’s specific needs, workforce characteristics and risk tolerance. Reviewing all relevant factors (e.g., rates, policy terms and potential exposures) can help employers decide whether purchasing this coverage makes sense. Employers can consider the following factors when evaluating whether to purchase stop-loss insurance.

Understanding the Attachment Point

The attachment points for individual and aggregate stop-loss insurance differ. Generally, the attachment point for an individual stop-loss policy is a specific dollar amount. As a result, an employer is only responsible for an individual employee’s claims up to that amount.

For aggregate stop-loss insurance, the attachment point is usually a percentage of expected claims. The typical attachment point for aggregate stop-loss insurance tends to be between 120% and 125% of expected health claims. In any case, a stop-loss insurance policy’s attachment point can vary depending on factors such as the employer’s size, employee demographics and overall risk profile.

Evaluating Coverage Limitations

Stop-loss insurance plans are medically underwritten; therefore, an insurer may refuse to cover certain conditions or require higher claim thresholds for those conditions. For example, if a plan enrollee consistently has high-cost claims, a stop-loss insurer may refuse to continue to cover that enrollee or require a higher claim threshold for the enrollee. This practice is known as lasering.

Additionally, since stop-loss contracts typically last for one year, an employer’s high-cost claimants may only be covered for a few months before the insurer excludes them from the policy upon renewal. Thus, the employer will likely be financially exposed to those claims the following year.

Monitoring Increasing Costs

While stop-loss insurance can help employers reduce their financial exposures when health claims are higher than anticipated in a given year, the cost of such coverage can increase annually. Rising claims can also make it more difficult to obtain rates from other providers.

Ensuring Stop-loss Coverage Aligns With Health Plan Provisions

Some stop-loss policies may exclude certain medical treatments or classes of individuals covered by employers’ health plans. Consequently, employers may be on the hook for expensive claims that aren’t covered under their stop-loss policies. Therefore, employers should consider reviewing their stop-loss policies and health plan provisions to ensure they align to limit their potential financial exposures.

Summary

Selecting the right insurance policies can have major financial repercussions for employers. Having sufficient coverage can lower employers’ insurance costs, reduce their risks and keep their workers healthy. Stop-loss insurance can make all the difference in helping employers mitigate their financial risks, especially as catastrophic health claims are increasing. Understanding stop-loss insurance will allow employers to make the best policy decisions for their respective organizations.

For more health care resources, contact RISQ Consulting today.