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Stop-loss coverage is catastrophic insurance coverage that may be built into the Extended Healthcare (EHC) portion of your employee benefits plan.
How Does Stop-loss Work?
Stop-loss coverage removes liability from your claims experience after an individual spends a set amount (the Stop-loss level). The cost of stop-loss is either based on a set monthly premium for the number of single/family employees you have on your EHC plan or it is based on a percentage of claims.
If your stop-loss level was $10,000, all claims within the yearly experience period for an individual above $10,000 would not add liability to the plan. For sake of the example, we will continue to use the $10,000 as an example stop-loss level throughout this article, but the actual amount for a group will vary based on the group size and usually ranges between $5,000 (only common now on older plans) to $15,000 (where the market is starting to move).
Stop-loss on an Insured Plan
For an insured plan, this means that all individual claims within the yearly experience period above $10,000 do not affect claims experience on renewal. Insurers base a business’ renewal cost for EHC on claims experience, inflation/trend and administrative costs. If one of your employees ends up on a high-cost drug that is $40,000 a year, your claims experience at renewal would only be $10,000 for that drug claim. This can keep your cost significantly lower as you have moved the catastrophic risk of a high claim over to the insurer.
Stop-loss for Administrative Services Only (ASO)
For an administrative services only (ASO) plan, all EHC claims within the yearly experience period above $10,000 are taken on by the insurer rather than paid out of your company’s benefit account. ASO plans work on a pay-as-you-go or budgeted basis where your business pays for claims rather than an insurer. For either style of ASO plan, once an individual on your EHC plan has over $10,000 of claims, any additional claims will get covered by the insurer instead of by your business.
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Adding Stop-loss to Your Benefits Plan
If you are starting a new benefits plan that has stop-loss coverage built-in, the insurer you end up with will likely choose your level of coverage (i.e. $10,000, $12,500, $15,000). Once you have claims experience, stop-loss becomes a conversation at renewal. The higher your stop-loss level, the lower your monthly Stop-loss premium will be. When facing the decision to increase your stop-loss, there needs to be significant savings, as you are adding more risk to your plan.
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