At a Glance
Riders
Contracts
Coverages
Stop Loss Insurance
We will help you fulfill yours.
Large claims over $1M increased from 3.5 per 100K lives to over 10 per 100K lives over 10 years2
Just 1% of people account for a quarter of total healthcare spending1
We own and deliver on our promise. Work with a carrier you can trust—for nearly 150 years, the Prudential brand has stood for strength, stability, and innovation.
Strength and experience
Choose from flexible policy options to build a coverage plan that works to address the financial needs of each self-funded plan and unique requirements of the business and employees.
Flexibility
Take advantage of streamlined processes across quoting, onboarding, and reimbursements. Benefit from our dedicated distribution team, who will work hand-in-hand with your existing relationships.
Ease of doing business
Fulfilling promises is what we do.
the coverage they
giving employees
so you can focus on
risk of self-funding,
We help reduce the
deserve.
Prudential
Why
to help protect your self-funded medical plan.
150 years of fulfilling promises, we have what it takes
As a leading financial services company with nearly
Coverages
Coverages
Coverages
More than 35 cell and gene therapies have received FDA approval and there are many more in the pipeline. The most expensive is over $4M.3
• Helps protect against higher-than-expected
frequency of claims for the overall covered population
Aggregate Stop Loss is more common for smaller to mid-size groups, as claims are less predictable with fewer covered members
Aggregate Stop Loss
Choose from two Stop Loss Insurance options, issued by The Prudential Insurance Company of America (Prudential)
Coverages
and
Aggregate.
101-250
Lives
251-500
Lives
501-1,000
Lives
1,001-1,500
Lives
1,501-2,000
Lives
2,001-5,000
Lives
5,001+
Lives
87%
5,001+
Lives
78%
66%
44%
46%
18%
7%
Percent of groups that purchase Aggregate coverage
• Coverage for: Medical Prescription drugs
Dental Short-term disability
Vision
101-250
Lives
251-500
Lives
501-1,000
Lives
1,001-1,500
Lives
1,501-2,000
Lives
2,001-5,000
Lives
5,001+
Lives
5,001+
Lives
$100K
$155K
$220K
$275K
$330K
$445K
$670K
Average Specific Deductible
by Group Size
With Specific Stop Loss, employers can pick a Specific Deductible, based on group size and risk tolerance.
• Helps protect against the severity of a single claim • Coverage for: Medical Prescription drugs
Specific Stop Loss
At a Glance
Riders
Contracts
Coverages
Specific
Source: Stealth Partner Group, Stop-Loss State of the Market Report, 2024
Source: Stealth Partner Group, Stop-Loss State of the Market Report, 2024
Aggregate.
Specific
Employers can customize and make the most of their Stop Loss Insurance coverage with these options
Riders
Specific Stop Loss Step-Down Rider
Reference Based Pricing Extension Rider
Plan Document Mirroring Rider
Enhance coverage with ...
Monthly Aggregate Accommodation Rider
Expedited Reimbursement for Specific Stop Loss Rider
Advanced Funding for Specific Stop Loss Rider
Help reduce cash flow volatility with ...
Gapless Run-Out Period at Renewal Rider
Renewal Rate Increase Cap Rider
No New Special Condition Limitation at Renewal Rider
Get more seamless renewals with ...
Specific Experience Refund Rider
Aggregating Specific Deductible Option
Potentially save money with ...
See it in action
How it works: This rider agrees to accept as Eligible Claim Payments, all Employee Benefit Plan benefits paid by the Contract Holder provided that such benefits are:
Paid in accordance with the terms of the Employee Benefit Plan
Incurred and Paid within the Reimbursement Basis
Paid under a covered benefit provided by the Contract
To help limit gaps in what is considered an eligible charge, we mirror the definitions of the Plan Document for these common areas:
Experimental or Investigative
Medically Necessary and Appropriate
Usual and Customary Charge
Value for employers: Helps minimize gaps between the employer’s Plan Document and the Stop Loss insurance policy in terms of what is covered.
Prudential guidelines:
We offer a Plan Document Mirroring Rider as a standard option with no additional cost/load as we quote new business
However, we will not officially issue this rider until the contract holder’s Plan Document has been submitted, reviewed, and approved by us
Plan Document Mirroring Rider
Experimental and Investigative
Clinical Trials
Medically Necessary
Reasonable and Customary
Caused by war, whether declared or undeclared, civil war, hostilities, riot, resistance to armed aggression
Expenses related to non-human organ or tissue transplants, xenographs, or cloning
Resulting from TPA approving alternative care or treatment, including waiver or plan provisions
Resulting from a criminal or illegal act or commission of a felony
Resulting from suicide whether sane or insane
Related to approved FDA/AMA Gene Therapy
Resulting from any complications in relation to a condition or service that is not covered under the
medical plan
Incurred as a result of travel within any foreign country with active U.S. Department of State Warning
Related to medical research
Treatment Administered outside of US, except for emergency situations
Claim expenses that are ...
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Stop Loss Contract Applies
How handled if Plan
Mirroring Rider IS in Place
Stop Loss Contract Applies
Stop Loss Contract Applies
Stop Loss Contract Applies
Stop Loss Contract Applies
Stop Loss Contract Applies
Stop Loss Contract Applies
Stop Loss Contract Applies
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Plan Document Followed
Stop Loss Contract Applies
How handled if Plan
Mirroring Rider IS NOT in Place
Plan Document Mirroring Rider
How it works: Reference Based Pricing refers to an alternative to traditional healthcare pricing that some employers, or their Third Party Administrator, use to adjudicate Eligible Claim Expenses under the Employee Benefit Plan.
The employer pays a set price for each healthcare service based on a reference, such as Medicare (e.g., 160% of Medicare reimbursement), instead of negotiating prices with providers, for example PPO, POS, EPO, or HMO networks.
This method replaces the Usual and Customary Charge
Value for employers: For claims being appealed under Reference Based Plans, this rider extends the Contract Basis.
Prudential guidelines:
Available on Reference Based Plans only and applies to reference based pricing claim appeals
Included at no additional cost/load
For claims being appealed, the reimbursement basis may be extended for 3-9 months
Reference Based Pricing Extension Rider
How it works: Can lower the Specific Deductible per Covered Person for claims where malignant neoplasms, premature infants, or organ transplants is a cost driver.
Value for employers: Provides additional protection for employers that have both Critical Illness and Stop Loss Insurance with Prudential.
Prudential guidelines:
The Specific Deductible per Covered Person will have a one-time reduction per Contract Period and the reduction will apply in the Contract Period which the Eligible Claim is Paid by the Employee Benefit Plan
The premium for the Group Critical Illness Insurance Contract is paid up to date
The Covered Person does not need to be covered for Group Critical Illness Coverage during the Contract Period
Specific Stop Loss Step-Down Rider
How it works: At renewal, the underwriting will not impose a new laser on any individual that wasn’t previously lasered.
At your next renewal: The deductible lasers that were set in place at new business can continue or be decreased, but we will not increase the laser for the renewal period If a newly emerging claim arises, the claim will be priced for in the renewal rate offering.
As an alternative pricing for a large claim, the customer or broker can request we quote a laser option for the individual instead.
Value for employers: Added protection at renewal.
Prudential guidelines:
If there are material changes to the plan, the No New Laser Rider may become null and void
No New Special Condition Limitation at Renewal Rider
How it works: This Rider guarantees the Specific Premium at renewal will not be increased more than the rate guarantee amount. Most often purchased with No New Special Limitations at Renewal Rider – these features are very prevalent in the market.
Value for employers: Added protection at renewal against very large price hikes.
Prudential guidelines:
Minimum Requirements: $50,000 Specific Deductible $350,000 of gross premium
Requires Underwriting Approval
Renewal Rate Increase Cap Rider
50% Renewal Rate Increase Cap
40% Renewal Rate Increase Cap
Standard Options
5.5%
Rate load to specific rates
10%
How it works: Any claims incurred during the Contract Period but Paid after the Run-Out Period will count against the renewal’s deductible.
Value for employers: Additional protection at renewal by eliminating the employer’s liability due to gaps in coverage between contract periods.
Prudential guidelines:
No additional load
Gapless Run-Out Period at Renewal Rider
This helps eliminate the financial burden for employers that may otherwise borrow funds to pay unexpected large claims and then wait for a reimbursement for that claim.
Value for employers: Provides employers with cash flow assistance for Specific Stop Loss claims, allowing them to access stop loss reimbursement dollars prior to their paying initial claims.
Prudential guidelines:
The Specific Deductible must be met
As a standard, request must be over $5,000 per Covered Person per claim
Automatically included for employers using TPAs, but not available for BUCA* administrators (Expedited Reimbursement Rider is offered to BUCAs instead)
Advanced Funding for Specific Stop Loss Rider
See it in action
Advanced Funding for Specific Stop Loss Rider
Employer's Third Party Administrator holds claim payment & submits claim detail for Advanced Funding to Prudential
Third Party Administrator releases the check to the provider
Employer will not be burdened financially for paying the full claim amount
No advance
Scenario
Advance requested
$500,000
Claim amount
$500,000
$50,000
Specific deductable
$50,000
$500,000
Claim paid by employer
$50,000
(specific deductable only)
$450,000
Reimbursement by Prudential
$450,000
7-10 days
# of days employer needs to wait for reimbursement
0 days (no initial outlay for claims above specific deductible)
Prudential reimburses the employer via the Third Party Administrator for the Advanced Funding claim
How it works: We will expedite reimbursements without a comprehensive claim audit being completed. However, at a later date, we will require a comprehensive claim audit, which will be completed as part of the Expedited Reimbursement Reconciliation Process.
Value for employers: Provides reimbursement of specific claims over $100K without initial audit; audit will follow.
Prudential guidelines:
Available for BUCA administrated cases only
Included at no additional cost/load
Expedited Reimbursement for Specific
Stop Loss Rider
Prudential guidelines:
Available on Groups with up to 500 employees for $2.50 per employee per month
How it works: Instead of reimbursing aggregate claims at the end of the policy period, this product feature will provide a monthly reimbursement when the year-to-date aggregate claims exceeds the year-to-date aggregate attachment point, which is the greater of:
The Accumulated Monthly Aggregate Attachment Point, which is based on monthly enrollment and the rate factors calculated during underwriting
The Accumulated Minimum Aggregate Attachment Point, which is determined during the underwriting process
The employer is expected to reimburse Prudential if in the month subsequent to a monthly payout by Prudential, the employers’ year-to-date paid claims dip below the year-to-date attachment point.
Value for employers: Provides advanced funding for the aggregate product, and is designed to assist smaller self-funded employers with cash flow during the policy period.
Monthly Aggregate Accommodation Rider
Prudential guidelines:
Premium is reduced by the same amount that the employer will be self-funding (dollar for dollar), creating a favorable proposition for employers—not all carriers offer this
The maximum Aggregating Specific Deductible is 30% of the net premium for Specific Stop Loss
How it works: The Aggregating Specific Deductible is a liability pool in addition to the Specific Deductible, for which the employer is responsible before any Specific Stop Loss reimbursements can occur. Once one or multiple covered persons in the employer’s plan reach the underlying specific deductible, the employer will continue to be responsible for claims until the additional liability pool is exhausted.
Value for employers: Potential to save money through lower premiums for employers able to assume a fixed amount of additional risk beyond the Specific Deductible assigned to each individual member. This fixed amount varies by employer and is determined during the underwriting process.
Aggregating Specific Deductible Option
Prudential guidelines:
Standard offering is 60% target net loss ratio at 25% share for a 5.5% pricing load
Available to employers with at least $200,000 premium annually who renew for a full plan year
Refund is typically within 6 months after the end of the benefit period
How it works: A portion of the Specific Stop Loss premium is paid back if the experience runs favorably as determined by the Net Profit Calculation. Net Profit is calculated as
% of the sum of all the Specific Stop Loss Premium minus broker commissions paid by Prudential; minus,
The sum of all Specific Stop Loss reimbursements for the Contract Period
Value for employers: Provides opportunity to save money for employers with strong experience by returning a portion of their Specific Stop Loss premium.
Specific Experience Refund Rider
At a Glance
Riders
Contracts
Coverages
Stop Loss Insurance
At a Glance
At a Glance
Riders
Contracts
Coverages
Learn more about our efforts in the stop loss market.
Download
Stop Loss Insurance flyer
Here's a closer look at the minimum requirements for Stop Loss Insurance quotes.
View minimal requirements
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1 KFF analysis of 2021 Medical Expenditure Panel Survey data 2 Aon, 2023 Employer Stop Loss Market Report, 2023 3 Federal Drug Administration, Approved Cellular and Gene Therapy Products, 2024 4 The Prudential Insurance Company of America has a grade A+ Financial Strength Rating from rater A.M. Best. A rating of A+ is the second highest of the 13 ratings rater extends. The rating is an
opinion on the insurer's financial strength and ability to meet its insurance policy and contractual obligation. Ratings are as of October 30,2024 and are not a guarantee of future financial strength or
claims paying ability. The ratings are subject to change and do not reflect any subsequent rating agency action.
- A.M. Best - A rating of A+ is the second highest of thirteen rating categories - Fitch - A rating of AA- is the fourth highest of twenty-one rating categories - Moody’s - A rating of Aa3 is the fourth highest of twenty-one rating categories - Standard & Poor’s - A rating of AA- is the fourth highest of twenty-two rating categories
Prudential Stop Loss is not available in all states and policy options may vary by state. Contact your Prudential representative for more information.
Group Insurance coverage is issued by The Prudential Insurance Company of America, a Prudential Financial company, Newark, NJ. The Booklet-Certificate contains all details, including any policy exclusions, limitations, and restrictions, which may apply. Contract Series: 113830
© 2024 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.
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