The prevalence of high-cost claims have gone up drastically along with the dollar value of those claims. The conditions resulting in claims greater than $1 million are more prevalent today due to advances in medical technology and improvements in life-extending care.
According to Sun Life, the 1,979 self-funded employers it counted as customers at the end of 2015 made 25 percent more claims of $1 million in the previous three years than they did in a similar report that came out a year ago.
Even though ACA has eliminated annual and life-time limits on essential health benefits; In your specific stop-loss agreement, unique coverage limits may still be applied to specific conditions, such as transplants, or in exclusions applied to individuals.
Stop Loss coverage that contains separate maximums can result in increased claim liability for the employer. Without a clear understanding of coverage gaps, an employer could face unexpected exclusions or claim denials. It is more important than ever that the plan’s existing inclusions, exclusions and limitations match the terms offered in the specific stop-loss contract.
Go for a mirroring endorsement in your stop-loss contract where carrier will cover everything that your plan covers. Also make sure that the definition and interpretation of terms such as medical necessity, preexisting condition and experimental and investigational treatment between the medical and stop-loss plans are consistent.
An oversight into this can significantly impact your cash flow and increase the financial risk.
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