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, 2017–2023
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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:
Each industry of employers is unique, and they select different administrators based on both their industry and size. There are advantages to both the Administrative services only model (ASO) and the Third-Party Administrator (TPA) option.
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 Sept. 2018 - Sept. 2023.
Understand coverage types
High-cost conditions and injectable drugs
Stop-loss product features
ASO
TPA
500-999
Under 100
200-499
1000–2999
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
3000+
Want to see more details for each segment?
Click on a chart bar to learn more!
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
We are committed to sharing data on high-cost claims trends to help you plan and design coverage that works for you. Want to learn more about conditions that may result in stop-loss claims? Check out our high-cost claims and injectable drug trends analysis for insights on top claim conditions, million-dollar claims, injectable drugs, and a deep dive into newborn-related conditions, cardiovascular, orthopedics/musculoskeletal conditions, and more.
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. 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. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2022 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. SLPC 30421 11/20 (exp. 11/21)
Monthly aggregate accommodation
Terminal Liability rider
SunExcel
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.
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
To help manage transplant costs, anytime your Third-Party administrator places a transplant contract with a nationally recognized transplant vendor, Sun Life will provide you with:
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
With Health Navigator care advisors your members have personal support to help make navigating the complicated healthcare system less challenging. From facilitating appointment with a specialist, to finding an expert second opinion, and collecting medical records, care advisors are there to give peace of mind that your members are receiving the right care, at the right place at the right time.
Since inception, Sun Life Stop-Loss has made over $1 million in additional reimbursement to our clients through the Employer Cancer Benefit.
1. Source: Sun Life book of business data through 2019.
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