We’re living in a world of high-cost claims. More companies than ever are experiencing health care claims over $1M*. Stop-Loss coverage can help. Let's take a look at the current landscape and need for Stop-Loss insurance.
*Source: Sun Life book of business data, 2019-2024
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Overview
Prevalence of a high-cost claim
Understanding coverage types
Selecting deductible levels
High-cost claims based on deductible levels
Stop-Loss product features
We will provide you with information on deductible levels, product options and other insights to help you design a Stop-Loss plan to work best for you and your clients.
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Using data to create a successful Stop-Loss plan
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High-cost claims by deductible level
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High cost conditions and injectable drugs
Download a copy of our 2021 High-cost claims and injectable drug trends report here.
Source: Sun Life book of business data including first dollar claims and stop-loss reimbursements from 2017-2020.
of employers had a COVID-19 related stop-loss claim in 2020*
3.5%
It is important to prepare for the risk of potential high-cost claims. As the highest-cost claims continue to rise, it is increasingly important to select the right stop-loss coverage options and deductible levels to ensure you are getting the protection you need!
86%
Any stop-loss claim
58.0%
An injectible drug stop-loss claim
58.5%
A cancer stop-loss claim
19.6%
A birth-related stop-loss claim
8.1%
A $1M+ stop-loss claim
*This number may change as 2020 benefit year claims continue to be processed.
6.
Employers have the option to decide what type of claims they’d like included under their specific coverage. The two options are medical claims and prescription drug (Rx) claims. Rx costs continue to rise with the expansion of conditions that drugs are used to treat and the emergence of new gene therapies at high price tags. As a result, more and more employers are selecting both medical and Rx coverage under their stop loss plan.
Choosing the type of benefit coverage that is right for you is the first step in selecting your stop-loss coverage. Here is the breakdown of employers that purchase specific only coverage, versus those who select specific and aggregate coverage by group size.
Aggregate coverage protects the employer from the situation when the total of all claims under the specific deductible level is higher than expected.
What is:
Aggregate Coverage
Specific Coverage
of employers decide to include Medical and Rx in their coverage
99%
Over
Source: Stop-loss quote requests that Sun Life received from Dec 2014 to Dec 2019. © Sun Life Assurance Company of Canada. All rights reserved.
Overall
Education
Health & Hospitals
Manufacturing
Mining & Construction
Public & Government
Finance, Insurance & Real Estate
Services
Transportation, Communication & Utility
SELECT AN INDUSTRY:
Employers' choice of health plan administrators depends heavily on their industry and size. Two main options are Administrative Services Only (ASO) and Third-Party Administrator (TPA) models. Each offers unique benefits suited to different sectors and organizational scales.
Third-Party Administrator (TPA)
Administrative services only (ASO)
Personalized service model and custom options for plan design, cost–containment programs, and vendors. Employers like it because… it supports choosing separate vendors for different services (sometimes called the “unbundled” approach, whereby different partners are selected based on their area of expertise).
Provided by Health Insurance carriers Access to proprietary provider networks—often national Standard service model, and set cost-containment programs. Employers like it because... ASO plans can work well for employers that are comfortable with the standard set of cost-containment programs and vendor choices. Employers that work with ASO plans report that fewer exchanges make a health insurance carrier feel less risky.
Specific coverage protects the self-funded company from large claims that may occur from any one covered individual.
Management Services
Wholesale & Retail Trade
Source: Stop-loss quote requests that Sun Life received from 2019-2024
Understand coverage types
High-cost conditions and injectable drugs
Stop-loss product features
ASO
TPA
When selecting between ASO and TPA, employers must consider their specific needs, workforce, and strategic objectives. This decision impacts costs, service quality, and employee benefit satisfaction.
Under 99
200-499
500-999
1000–4999
Determining the right deductible level for your group is an important step in designing your stop-loss coverage. Employers pick deductible levels based on the size of their group, risk tolerance, cash flow, demographics and industry.
Choose your group size below:
Calculate the numbers of stop-loss claims you may experience during your Policy Year based on your size and selected specific deductible.
100-199
5000+
Want to see more details for each segment?
Click on a chart bar to learn more!
45%
0%
2%
47%
6%
11%
59%
27%
4%
29%
65%
1%
18%
5%
75%
13%
52%
34%
66%
42%
53%
7%
19%
74%
16%
50%
39%
57%
35%
8%
31%
17%
12%
15%
28%
60%
43%
23%
10%
56%
44%
21%
62%
24%
9%
71%
30%
54%
14%
3%
36%
33%
22%
Liveborn jumps into the top 5 highest cost claims for deductibles over $250K.
Mental disorder claims only appear in the top 5 for groups with a deductible level under $50K.
Click here to see different top-10 lists based on size and industry!
Based on the deductible level you select, the highest cost claims you may expect to see can vary widely. This is also true based on your industry.
Source: Percentages are the likelihood in a given benefit year of having a stop-loss claim. The calculation uses data from 2016-2020 benefit years.
All Deductible Levels
$51,000–$100,000
$101,000–$250,000
$251,000–$500,000
OVER $500,000
Dorsopathies (spine) claims only appear in the lower deductible levels, $50K and below.
$0–$50,000
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. Armed with these insights, you'll be better equipped to refine your risk management strategy, optimize your benefit offerings, and stay ahead of industry shifts.
Group stop-loss insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 07-SL REV 7-12 and 22-SL. In New York, Group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12 and 22-NYSL. Policy offerings may not be available in all states and may vary due to state laws and regulations. Not approved for use in New Mexico. © 2025 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. GSLCR-10822 #1663457501 05/25 (exp. 05/27)
Monthly aggregate accommodation
Terminal Liability rider
Expert Cancer Review
Aggregating specific deductible
Cancer rider
Experience rating refund
CLICK TO Choose a term to see the definition.
No New Laser with rate cap
Health Navigator
Reduce the financial impact of monthly claim volatility on your self-funded plan with the Monthly Aggregate Accommodation option. This option helps limit your monthly aggregate claim liability by providing an accommodation for amounts that exceed the accumulated monthly attachment point.
As soon as you exceed the accumulated monthly attachment point, your plan administrator sends in an accommodation request, and we send that amount to you. At the end of the policy period, one calculation will be made (comparing the total aggregate paid claims to the aggregate attachment point) to determine if the employer must refund any portion of the monthly accommodations made during the policy period.
Want to learn more?
TLO extends Stop-Loss coverage for 3 months immediately following policy termination.
Our Terminal Liability option (TLO) provides extra protection for a policy. In the event that the Stop-Loss policy is cancelled, our TLO places a cap on the plan’s claim liability.
Terminal Liability Option
Flexibility to use your TPA’s preferred transplant vendor and still qualify under the program
Employer reimbursement of up to $5,000 for travel and lodging if covered under the medical plan
A stop-loss Specific deductible reduction of up to $10,000 per transplant
Expert Cancer Review (ECR) provides covered individuals diagnosed with cancer, or undergoing cancer treatment with an objective, written second opinion from an oncology specialist at Sun Life’s expense. With access to the right cancer specialists through Expert Cancer Review, employees can be better informed and make more confident decisions about their cancer care, leading to improved outcomes and potential cost savings.
The Aggregating Specific deductible is simply an additional deductible that must be met before we begin to pay Specific claims. The employer meets the deductible with claim amounts that exceed the Specific deductible.
of our book of business has the aggregating specific deductible as an additional layer of protection
th
1/4
Nearly
Aggregating Specific Deductible
With cancer being a leading cause of high-cost claims, it is important for employers to develop a strategy to address the potential high costs of cancer. For employees, the Critical Illness and Cancer product benefits them directly if they, or one of their dependents, gets diagnosed with a covered condition. There are no restrictions on how this money can be used by the employee. The Sun Life Stop-Loss Cancer rider provides a specific Stop-Loss deductible reduction, resulting in an increased reimbursement to the employer.
One of the advantages of self-funding is the opportunity to save when claims run lower than expected. Self-funded employers can also be rewarded for positive claim experience through their stop-loss policy. Add the Experience Rating Refund Endorsement so you get the opportunity to receive a portion of your stop-loss premium dollars back.
A “laser” is a higher deductible, a coverage limit, or an exclusion placed on an individual who has incurred or may incur large health care claims. With this option, when the policy renews, no new lasers will be applied to the renewal policy year, unless requested by the policyholder.
of our clients have no new laser with rate cap as a part of their policy
80%
Almost
Every stop-loss claim represents a person and a family going through a challenging time. We believe providing people with expert, objective health support and guidance before, during, and after a high-cost claim creates a better healthcare experience, provides access to the best care, and improves health outcomes. And in doing so, also improves healthcare costs and impacts high-cost claims.
Since inception, Sun Life Stop-Loss has made over $3M in additional reimbursements to our clients through the Employer Cancer Benefit.
1. Employer cancer benefit step-down claims payments as of June 2024
1
1. Source: Sun Life book of business data through 2019.
Learn more about our product features here!
Sun Life’s #1 high-cost claim condition year after year.
Cancer is a top concern for self-funded employers
of Sun Life stop-loss clients are likely to have a cancer-related high- cost claim in a given benefit year.
1. Source: Sun Life Stop-Loss book of business
Leading to a better member experience and improved outcomes • Successful navigation of the complex healthcare system • Confidence in health decisions • Improved health outcomes, often leading to reduced costs
