Stop-Loss Contracts 101: Protect Your Business from Health Costs

Stop-Loss Contracts 101: Protecting Your Business from High Health Costs

For employers with self-funded health plans, minimizing financial exposure to catastrophic healthcare claims is crucial, especially as these claims become more frequent due to rising costs. Stop-loss insurance is a critical tool for self-funded employers, offering protection against higher-than-expected health claim expenses by capping their liability for medical claims that surpass a specified threshold. This insurance helps manage healthcare costs and safeguards against severe and frequent claims, ensuring that extraordinary claims do not deplete an employer’s financial reserves.

Stop-loss contracts vary widely, with numerous options and riders available to help employers align their coverage with risk tolerance, cash flow, and long-term claims strategy. As more self-funded employers invest in stop-loss insurance to mitigate their exposure, understanding these contracts becomes essential for selecting the appropriate coverage. This article will provide an overview of stop-loss insurance, detailing how stop-loss contracts work and exploring their various contract periods.

Understanding Stop-Loss Insurance: Managing Healthcare Costs and Protecting Against Catastrophic Claims

Overview of Stop-Loss Insurance

Stop-loss insurance is crucial for self-funded employers and is designed to help manage healthcare costs and protect against unexpected or catastrophic claims. This insurance sets a financial limit on the amount employers will pay for health claims, providing a safety net for unusually high expenses. Unlike traditional health insurance for employees, stop-loss insurance is an additional policy that can be added to an existing health plan or purchased separately.

Under a stop-loss insurance policy, an employer's liability for claims is capped at a specific amount known as the attachment point. If the health claims surpass this threshold, the insurer typically reimburses the employer for the excess amount. For instance, with an attachment point of $100,000, the insurer would start covering costs once claims exceed this amount. Before reaching the attachment point, the employer remains responsible for paying the claims.

Types of Stop-Loss Insurance

There are two types of stop-loss insurance: specific (or individual) and aggregate (or total claims).

Specific Stop-Loss Insurance

This type of insurance limits an employer’s liability when an individual employee’s medical claims exceed a predetermined attachment point. It offers protection against unexpectedly high costs from individual employees, ensuring that the employer does not bear the entire financial burden of a substantial claim from any single person.

Aggregate Stop-Loss Insurance

Aggregate stop-loss insurance protects employers from the total sum of health claims for an entire group of employees. Instead of focusing on individual claims, this coverage caps the overall claims expenditure for the entire group, providing a safeguard against higher-than-expected total claims.

Employers can opt for either or both types of stop-loss insurance to maximize their financial protection and manage their risk exposure effectively.

Types of Stop-Loss Contracts

Stop-loss contracts generally fall into three categories: paid, incurred, and incurred and paid.

Paid Contract

A paid contract offers comprehensive coverage by addressing claims incurred on or after the effective date of the stop-loss contract. This type of contract is often available only upon renewal and does not cover exposures arising after the contract period ends. For instance, if a paid contract is effective from January 1, 2023, it covers claims incurred between January 2022 and December 2023 (24 months) and paid between January 2023 and December 2023 (12 months). This covers claims incurred before the contract's effective date but remains unpaid. This type of contract is sometimes called a 24/12 or referred to as having "run-in" coverage.

Incurred Contract

An incurred contract covers claims incurred during the contract period and paid within a specified timeframe after the end of the contract period, typically 90 days. Some variations extend this period to six or twelve months post-contract. This type of contract is also known as a 12/15 or referred to as having "run-out" coverage.

Stop-Loss Insurance Contract Periods: What Employers Need to Know About Coverage

Stop-loss insurance policies feature various coverage periods, determining when claims are eligible for reimbursement based on their incurrence and payment dates. Employers must be mindful of these periods to avoid paying for claims outside the policy’s adequate timeframe. For instance, if an employer renews their stop-loss insurance policy effective January 1, but a claim incurred on December 1 of the previous year is billed after January 1, the employer may need to cover this claim if their policy only covers claims within the policy period.

12/12 Contract Period

A 12/12 contract covers claims incurred and paid within the same 12-month period. Claims incurred during this period but only paid after the contract ends are considered immature claims. Employer opts for a 24/12 contract period to cover such claims after their 12/12 contract ends, ensuring coverage for claims incurred in the previous year but paid after the 12/12 contract period.

12/15 Contract Period

A 12/15 contract period covers claims incurred during the 12 months and paid within 15 months. This protects against claims incurred during the policy period but not paid by the end of that period. Variations such as 12/18 and 12/24 are also available, offering extended payment periods.

15/12 Contract Period

A 15/12 contract period covers claims incurred within the three months before the policy’s effective date and paid during the 12-month policy period. This extension allows claims incurred during either the 12 months or the three months before the policy’s start date to be eligible for coverage. Other common periods, such as 24/12, may add 12 months to the incurred dates with each renewal (e.g., year one: 24/12; year two: 36/12; year three: 48/12).

Conclusion: Safeguard Your Organization with Effective Stop-Loss Insurance

Stop-loss insurance is crucial for employers to manage escalating healthcare costs and maintain financial stability. Employers must clearly understand contract periods and coverage specifics to benefit fully from stop-loss insurance. With this knowledge, organizations can avoid facing significant claims that may not be covered under their current policies.

For expert guidance and to explore how stop-loss insurance can enhance your organization’s financial protection, reach out to Custom Benefit Consultants (CBC), Inc. today.

Contact us now for expert advice and comprehensive resources on effectively managing your healthcare benefits, including small business insurance online quotes .

FAQs

What Is Stop-Loss Insurance and Why Do Employers Need It?

Stop-loss insurance is a protective policy for self-funded employers that caps the amount they pay for high health claims. It helps limit the employer’s financial exposure to large claims, ensuring that unexpected or catastrophic health expenses don’t severely impact the company’s finances.

How Does an Attachment Point Work in Stop-Loss Insurance?

The attachment point is a threshold the stop-loss policy sets, determining when the insurer begins covering claim costs. For example, if an employer's attachment point is $100,000, the employer is responsible for all claim costs up to this amount. Beyond this threshold, the stop-loss insurer reimburses the employer for additional expenses.

What’s the Difference Between Specific and Aggregate Stop-Loss Insurance?

Specific stop-loss insurance limits the costs an employer pays for individual claims, protecting against high claims from a single employee. Aggregate stop-loss insurance, on the other hand, covers the total sum of claims for all employees, safeguarding the employer from unexpectedly high overall claims.

How Do Stop-Loss Contract Periods Affect Coverage?

Contract periods determine the timing of eligible claims based on when they are incurred and paid. For instance, a 12/15 contract covers claims incurred during the policy year but allows three additional months for payment. Employers must choose contract periods aligning with their cash flow and claims processing needs to ensure comprehensive coverage.

FAQ 5: What Should Employers Consider When Selecting Stop-Loss Coverage?

Employers should carefully assess their risk tolerance, cash flow, and claims experience. They should also review contract terms, attachment points, and available riders or customization options. Consulting with a benefits expert can help employers select the stop-loss contract that best aligns with their financial and operational goals.