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Stop-loss Insurance takes claim off the Employer’s shoulders
When an employee has a health issue requiring expensive treatment, the associated high-cost claims can be significant for their benefits plan sponsor. But it’s impossible to predict when a large claim will arise, so stop-loss insurance, which takes the claim off the employer’s shoulders, is one option to help protect against these unexpected costs.
As a type of insurance policy that sits on top of a benefits plan, stop-loss is available to both fully- and self-insured plan sponsors. When choosing stop-loss insurance, an employer selects a threshold up to which it can reasonably cover claims — ranging from between $10,000 and $100,000 — and any claims beyond that will be covered by the policy.
Stop-loss not a substitute for plan management
The main benefit of stop-loss insurance is its ability to protect the Saskatoon employer from catastrophic claims. For self-insured groups, it primarily acts as a budgeting tool so there aren’t any unexpected hits that could affect accounting.
On the other hand, stop-loss can become costly. While a claim may be mitigated in the first year, premiums can rise in the following years, essentially providing only short-term stabilization. This is especially difficult if the claim is reoccurring, which is the case for most drug claims.
“Stop-loss doesn’t help you avoid cost; it simply helps you prevent an unexpected surge in costs in a given year. It’s not a substitute for plan management.”
Another drawback is that most plans only have a single market for stop-loss insurance, meaning employers can only purchase it from one group, typically their own health insurer, which limits them to that insurer’s quote.
To limit risk, employers can use a pre-existing condition clause for an employee’s first year of employment by setting benefits to a specific limit so they can’t bring in unexpected expenses. Another option is to put a limit on drug reimbursement levels or incorporate provincial drug programs into the benefits plan.
While stop-loss prevents large, unexpected claims from affecting a plan sponsor, it’s important to understand that issues can still arise after a claim is made and employers should be aware of all the available options, so they can make a decision before it’s too late.
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