Dave's Stop-Loss Digest
Hi my name is Dave, and I'm glad you stopped by.
Thank you for visiting my resource page! Please scroll below to find my monthly video newsletters and the digital tools you need to succeed in the self-funded marketplace.
I have been with Sun Life since 2021 and am here to assist you with all your stop loss needs. My mission is to deliver excellent stop-loss coverage and healthcare solutions to our partners across the Sunshine State. Think of this page as your one-stop shop for anything you need to succeed when it comes to self-funding.
Meet Adam
Please reach out to me at any time: David.Chiokadze@Sunlife.com
On a personal note, my wife and I live in Fort Lauderdale with our sons Luke and Bradley. When I have free time, you can find me playing ice hockey or guitar. We also love to visit family in Philly, where I was born and raised.
I look forward to achieving success together and hope you enjoy the content below!
Sun Life supports our clients with competitive pricing and consulting that has made us the number one independent stop-loss carrier in Florida and America. Our team will work with you to achieve your client’s objectives and ensure they have appropriate coverage along with access to care.
Digital experiences
Thought leadership and resources available to you!
Featured content: Clinical 360+
By enhancing Sun Life’s industry-leading Clinical 360 program, we can provide targeted, health capabilities to deliver better health outcomes and cost savings for our stop-loss clients. Giving clients access to better care, preventive health support, and care navigation for their employees, and the member engagement support to enable it all.
Medical Rx 360
Sun Life and Hinge Health
Kidney Care 360 and Heart Care 360
Sun Life Clinical 360+ Overview
Click here to learn more about ERR
November 2024 - Experience Rating Refund
Watch the video for more!
Sun Life is committed to bringing solutions to employers that will have the biggest impact on their self-funded plans and improve health outcomes and affordability for members. Sun Life has selected OptiMed Health Partners as a preferred partner—enhancing our industry-leading Clinical 360 program with a solution to help manage the rising costs of specialty Rx medications and deliver a better care experience for members.
Watch my video or click anywhere on the yellow chart to learn more!!
October 2024: 3% Off Stop Loss + Savings on Injectable Drugs via OptiMed
Click on some of the topics below to learn more or reach out to me directly if you have questions!
September 2024: Stop-Loss Differentiators
• Any Plan design changes along with any proposed additional Stop Loss features (ex. alternative Stop Loss deductible levels)
• We can firm up Stop-Loss Renewals with claims through September. However, depending on the risk of the group, we may be able to firm up 1/1/2025 cases with claims through August.
• From a New business side, we can also firm up 1/1/25 cases with claims through August.
• Census: Name, Date of Birth, Gender, Zip Code, Singe/Family Status, which medical plan they are in, and Retiree if status if covered
To Request your Sun Life Stop-Loss Renewal for the 4th quarter, please send all materials to stoplossrenewals@sunlife.com and cc me:
Check out my video or the flyer above to learn more about what you'll need for renewal.
August 2024: Are you ready to renew with Sun Life?
• It’s fast – reimbursement is generally available within 48 hours from receipt of approved claims data.
• It’s convenient – you can use it for all claims that are above the Specific deductible or just on large claims.
• It’s trackable – we send you an e-mail with an explanation of reimbursement (EOR) each time a reimbursement is sent.
• It’s green – Accelerated ASO Reimbursement is paperless and good for the environment.
Accelerated ASO Reimbursement
Services are provided to all our stop-loss clients at no cost and are particularly useful for large claims
July 2024: Expedite Sun Life’s reimbursement process!
Organizations are faced with new challenges every day—rising medical costs, a competitive market for attracting and retaining talent, and a complicated healthcare landscape to name just a few. To combat these challenges, it is important to look at benefits differently. Focus cannot just be on managing risk, but also on the overall health and well-being of employees.
Combining PinnacleCare’s health expertise with Sun Life’s market-leading benefits and risk solutions, we can support better health outcomes for members and employers with Health Navigator, powered by PinnacleCare.
June 2024: SAVE BIG with Health Navigator!
• 72% of all stop-loss claims came from the top 10 conditions.
• For the first time since we began producing this report, Cardiovascular has moved into the #2 spot for highest reimbursement over the four-year view; Leukemia, Lymphoma, Multiple Myeloma is now #3.
• Five new drugs are on the 20 high-cost injectable drugs list in 2023; two are used primarily in the treatment of cancer, one for immunodeficiency disorders, one for gout, and one for blood disorders.
• The top 10 injectable drugs all had over $10M in total spend; Keytruda is still at #1 with $69.7M in spend.
• Over the benefit years from 2019-2022, 87% of employers were likely to experience a stop-loss claim in any given year.
• Million-dollar claims rose 8% on a claims-per-million-covered-employees basis over the past year, and are up 50% over the past four years.
• 32 members had a claim over $3M; nine of those claims were over $5M, with the highest claim over $11M.
• 50% of our members with a $3M+ claim were impacted by Congenital Anomalies.
Highlights and key statistics from the Report:
Click here to explore more!
May 2024: The 12th high-cost claims and injectable drug trends analysis!
April 2024: Gene Therapies NNL Enhancement
Click here for key terminology
For April's topic, let's talk about Sun Life's new enhanced coverage!
We are improving our gene therapy offering! For new and existing clients with a “no new laser” stop loss Policy with an effective date on or after July 1st 2024, Sun Life will not add a laser or adjust an existing laser directly related to the cost of Gene Therapy Drugs.
• Specific deductible: When a stop-loss insurance policy is in place, the deductible level is the portion of the claim risk that the employer retains and the amount above the deductible is reimbursed according to the stop-loss plan
• Aggregate attachment point: The amount the employer must pay during the claims basis before Sun life would be able to reimburse the aggregate claim. The aggregate attachment point is based on the projected total expenses for the company then a margin (corridor) is added
• Covered unit: Categories of covered persons within the plan. They may be: employee only, employee + 1, employee + spouse, employee + child(ren), family.
• Eligible expenses: Medically necessary and appropriate expenses incurred by a covered person that Sun Life will pay through the Stop-Loss policy. Expenses are considered eligible if: 1) they are covered within the employer’s underlying plan, 2) the date of service and paid date fall within the claims bases, 3) they are paid under a covered benefit, 4) not excluded from the policy
• Claims basis (contract basis): identifies the claims date of service (incurred) and paid dates for which a claim will be covered under the stop-loss plan. It helps determine an expense’s eligibility. Common choices are:
o For example: if a group has a $150,000 deductible, a $175,000 claim would be reimbursed $25,000 by the stop-loss insurance
o 12/12 (Incurred in 12/Paid in 12): This choice covers claims incurred and paid within the 12-month benefit period. When the policy renews, this contract often reverts to a “Paid” contract basis.
o 15/12 (Incurred in 15/Paid in 12): This “run-in” choice covers claims that occur within a 15-month period and paid during the 12-month contract period. The 15-month period includes the 3 months prior to the start of the Stop-Loss contract period. If your company changes administrators, 15/12 is the best run-in contract offered.
o 12/15 (Incurred in 12/Paid in 15): This “run-out” choice covers claims incurred during the 12-month contract period and paid within a 15-month period. The 15-month period includes the 3 months after the end of the Stop-Loss contract period.
o Note: Other run-in and run-out choices are available (e.g., 12/24, 24/12). Sun Life must approve the Contract Basis
Key Terminology:
December
November
october
September
August
July
June
May
April
amazing topics to explore
Click below by month
2024
Here is an archive of content featuring key topics and information.
Definitely check them out, and feel free to share the resources with your clients and colleagues.
If you’d like additional information on any of the key information, please let me know!
2024
Future Forecast
CAR-T Immunotherapy
Sun Life NNL
Gene Therapies
Welcome to my brand-new stop loss video series!
Watch my video and click through the materials to learn more. Happy to field any questions you may have on this topic!
Check out my video for more info!
Resources for you:
2025 high-cost claims report
Product Options Overview
Clinical 360 overview
RX Standard + Rx Plus
Health Navigator alongside Stop-Loss
Gene Therapies whitepaper
Self-funded playbook
Cancer
rider
• Enhances the cash flow of your self-funded plan
• Provides you or your administrator with the cash flow needed to pay eligible claims-related expenses
Advance Funding
Check out the flyer to learn more!
Want to learn more? Check out the Advance Funding flyer!
Watch my quick video for key points and highlights!
• Monthly Aggregate reporting with lives and claims by covered product (Medical, RX drug, Dental, Vision, STD) - and if applicable, include reporting for the current plan year, full prior plan year, and run out from the prior TPA
• Individual large claims with diagnosis for claimants that are 50% or more of the deductible with diagnosis with reporting dates, 1/1/23-12/31/23 and 1/1/24-8/31/24
• All Current and proposed TPAs/Networks along with the current plan document including any amendments
You can also request a renewal benchmark any time!
ASO Accelerated Reimbursement
Early Lock
No Gene Therapy Lasers
Mirroring Endorsement
Renewal Rate Cap
No New Laser Renewal
TPA Advance Funding
Ancillary Cross-Sell (2-8% Discount)
(3% off Agg deductible factors)
(10% off Spec deductible)
Health Navigator
OptiMed Medical Rx (3% Discount)
Sun Life Clinical 360+
Benchmark Report
Experience Rating Refund
Key Features
Solutions
Watch my video too!
Experience Rating Refund (ERR) can deliver as much as a 10% premium refund to group’s who perform well or 50% of the surplus (the lesser of the two).
Happy Thanksgiving!
Happy Holidays!!
The new year is coming up so let's take some time to get reacquainted with our Stop-Loss contract using the "Understanding your stop-loss policy" tool. With easy-to-understand plain language explanations, you and your clients can review Sun Life's policy details. Please let me know if you have questions!
December 2024: Happy Holidays from Sun Life!
Watch my video or click on the image to learn more!
From my family to yours, Merry Christmas, Happy Holidays, and Happy New Year! Wishing you all the best for 2025 and cannot wait to connect in-person.
August
July
June
May
April
March
February
January
amazing topics to explore
Click below by month
2025
Pick a year!
2024
2025
Click here to review a sample benchmark report
January 2025: Customized benchmarking
This month is all about Sun Life’s benchmark reports which use our vast book of business to create tailored reporting for your clients.
Or watch my video to learn more!
Benchmark reports are great for having those self-funding conversations with your fully insured clients or considering buying up in deductible. Best-in-class insights that can be produced quickly (typically within 24 hours upon receiving a census), have us run one for you today!
Click here to learn about our Sun Life Dental Best Partner Cross Sell offering!
February 2025: cross-sell
This month is all about how your clients can benefit from our cross-sell discounts via our Sun Life Employee Benefits Reps.
These discounts typically range between 2-8% off our spec premium and will be brought to your attention during the new business and renewal process.
Watch my video to learn more!
Click here or on the image to the right to see an overview on how Kidney Care 360 and Heart Care 360 can help!
March 2025: Kidney and Heart Care
Sun Life is proud to offer our clients a suite of cost containment services at no cost via our Clinical 360+ platform. Among these are Somatus for kidney and heart care, OptIMed for medical Rx injectables and Hinge for MSK.
This month, we are focusing on how Somatus helps claimants with kidney disease better manage their conditions.
Clinical 360+ is currently available via our preferred TPA partners who have agreed to provide us with eligibility for seamless implementation. Please keep this solution in mind as you come across claimants that could benefit from better managed kidney disease and related conditions. Check out my quick video to learn more!
Sun Life and Hinge Health are working to transform the way musculoskeletal (MSK) pain is treated—providing pain relief for members and reducing cost and productivity impacts for employers. Using advanced technology, a team of clinical experts guide members through personalized exercise programs for comprehensive joint and muscle pain.
April: Sun Life + Hinge Health
Click below or on the image to learn more:
• Hinge Health flyer
• Webinar recording
• Hinge Health video
• MSK spotlight
Check out my video!
NEW: Sun Life's
Expert Cancer Review
Sun Life’s Expert Cancer Review (ECR) provides covered individuals diagnosed with cancer or who are currently undergoing cancer treatment with an objective, written second opinion from an oncology specialist at Sun Life’s expense. Automatically included for Sun Life Stop-Loss clients at renewal or new business beginning with 7/1/2025 effective dates, excluding captive clients.
Promotional slides
ECR overview
For the past 13 years, Sun Life has been at the forefront of analyzing our comprehensive claims data to empower self-funded employers. Our mission: to provide crucial insights into high-cost claims and injectable drug trends, enabling self-funded employers to make informed decisions that benefit both their employees and their bottom line.
Top 50 injectable drugs deep dive
Link to the full report
Top conditions by size and industry
Featured content: 13th annual high-cost claims and injectable drug trends report
May: high-cost claims
Thirteen years ago, Sun Life published its first report on high-cost claims. Our objective was simple and remains unchanged: empower self-funded employers and the brokers who support them to make smart, data-informed coverage decisions using insights from our robust claims experience and expert data analysis.
This year's report contains:
• Evolving landscape of high-cost claims. Top 20 conditions and million-dollar claims
• Impact of market dynamics on healthcare trends and experiences
• Deep dive into orthopedics/MSK, newborn care, cardiovascular disease, and cancer
• High-cost injectables. New entrants and emerging drugs to watch
• Proactive strategies for better health outcomes, care optimization, and risk management
Transform your organization's healthcare strategy and bottom line through actionable insights
Webinar and report link here!
HCCR webinar recording
Sun Life’s Expert Cancer Review (ECR) provides covered individuals diagnosed with cancer or who are currently undergoing cancer treatment with an objective, written second opinion from an oncology specialist at Sun Life’s expense. Automatically included for Sun Life Stop-Loss clients at renewal or new business beginning with 7/1/2025 effective dates, excluding captive clients.
ECR overview
June: Expert Cancer Review Launching! Sun Announces Remote Second Opinion at No Cost
ECR is completely voluntary, and groups will be auto enrolled so there is nothing to do on your end for implementation. Reach out if you'd like to view an ECR written opinion sample!!
July 2025: 1 year of Gene Therapy NNL!
Can you beleive it's been 1 year since we launched our gene therapy NNL enhancement?
This month, I wanted to share a reminder that Sun Life no longer lasers for the cost of gene therapies. That being said, Sun Life will continue to employ strategies to mitigate the impact of high-cost gene therapy claims on our clients’ stop-loss renewals. This provision comes standard with all no new laser contracts at no additional cost.
Learn more by clicking here!
August 2025: Is my renewal ready? Locking Early with Sun Life Stop Loss
Key reminders about Sun Life's locking process for both Renewals and New Business
- Please let us know of any acquisitions the group has made or intends to make.
- We can lock early without a load to our rates on certain cases.
- Any groups that add ancillary coverage via Sun Life are eligible for 2-8% off spec premium.
- Groups that purchase Health Navigator are eligible for spec discounting along with: 10% off specific deductible, 3% off aggregate factors
- Groups using our TPA partners, under 200 lives are eligible for Clinical 360+ at no cost
RFP Underwriting Checklist
Renewal Specific Coverage Requirements
Renewal Specific Coverage Requirements
• Large claim information, per claimant, and/or catastrophic conditions as outlined on the Renewal Request Letter
o For amounts over $25,000, with diagnosis and prognosis, for the 10 months prior to the renewal date
o This applies to deductibles under $150,000; for deductibles at or over $150,000, information is needed for claims over $50,000
• A Current Census that includes:
o DOB
o Gender
o Employee Home Zip Code o
o Active Status and Medical Tiers.
o Employee Date of Hire
o Employee Medical Effective Date
o Dependent Name, Gender, and DOB
o Dependent Medical Effective Date
o Medical Plan Election
• Aggregate reports for the past 2 years, including run-out claims from other carriers
• Monthly claims and lives by line of coverage
• Claims paid over the specific deductible
• Copy of the current Plan Document
• Any recent amendments or proposed changes
Renewal Aggregate Coverage Requirements
Renewal Aggregate Coverage Requirements
September: 10% Off Spec with Health Navigator!
HN is there to help during a challenging diagnosis, and it also reduces the Spec Level by 10% for any member who reaches out to their care advisor regarding their condition prior to breaching their deductible.
Along with the spec buy-down, Sun also provides a 3% Agg Factor Reduction for groups who purchase this service. We can add it to any of our in-force groups, so please let me know If you’d like to learn more!
Learn more by clicking on the flyer pictures
Hear more details from my video!
October
September
October
November
October: Rx Carve-Outs Made Simple
Sun’s Rx Standard service, which comes at no cost, combines medical and Rx claims, so you don’t have to.
For a small fee, we can have that process setup via FTP feed instead of email - that’s our Rx Plus service.
FAQs:
Rx Standard
and Rx Plus
See how they compare:
Watch my video to learn more!
November: gapless renewals
Watch my video to learn more!
This month is all about Sun Life’s Gapless Renewal Provision which is included in all our run-out contracts.
When this option is selected, any eligible expense incurred after the original effective date of the Sun Life Specific Stop-Loss policy but paid after the run-out period is eligible under the subsequent renewal policy year and is reimbursed once the renewal policy year deductible is met.
How it works:
