Symetra Benefits Blog

48-hour reimbursements for catastrophic stop loss claims

We’re known across the nation for writing clear, user-friendly policies that eliminate gaps between what plans cover and what is eligible for reimbursement; and for following through on our promises by paying claims on time, or ahead of schedule—even the ones considered large or catastrophic. Our innovative Preferred ASO Claim Advance option can significantly reduce your clients’ wait time for large or catastrophic claims—with reimbursements paid within two business days.

Learn more about Symetra stop loss 

Stop Loss in 2018: cost vs. value; striking the right balance for your self-insured clients (part 4)

Part 4: Underwriting practices—is the policy renewal-friendly?

In this series, we examined our evolving stop loss market, contract quality and claims service. In addition to these critical details, it’s important to ask potential stop loss carriers about their underwriting practices before signing a contract.

Some things to consider:

• Stop loss is an annually renewable policy and we see a wide range of renewal underwriting practices. If a customer’s loss ratio exceeds established tolerance levels (known as the “target loss ratio”), some carriers will set renewal pricing based solely on the customer’s unique experience. Other carriers may partially “pool” the needed increase by applying it across their national block of business. Carriers with smaller blocks of business and MGU’s are more likely to set renewal pricing based on individual case performance.
• If your carrier partner has rigid underwriting practices and forces clients into difficult maximum liability scenarios for the renewal period, finding a suitable replacement carrier could be challenging. If, for example, a participant has a known condition requiring a prescription that runs $70,000 per month, some carriers will build expected claims in excess of the deductible directly into the renewal premium.
• Does the carrier require a signed disclosure form at policy renewal?
• Does the carrier reserve the right to "laser" plan participants at renewal or increase existing lasers at renewal? (A “laser” is a deductible level higher than the individual stop loss case levels.)
• Does the carrier offer a renewal rate cap? This option might come into play if claims experience has been adverse, or if there are ongoing significant claim liabilities in the new policy year for which the carrier may need to rate.

When you’re evaluating carrier options, take time to review their renewal policies so there are no surprises in the future.

We hope you enjoyed this four part series and gained some insight into things to consider when choosing a stop loss carrier. If you have any questions, or want to learn how Symetra’s stop loss policy stacks up, please contact your Symetra stop loss representative.

Stop Loss in 2018: cost vs. value; striking the right balance for your self-insured clients (part 3)

Part 3: Claims service— How efficient and proactive is your carrier partner? Cash flow is king!

In earlier posts we explored how the stop loss market continues to evolve and things to look for in a stop loss contract. Another important factor to consider when evaluating potential stop loss carriers is claims experience.

Some questions to ask:

• Does the carrier have 100% claim authority for reimbursements to your clients? Or, do they first require authorization from their reinsurer before a claim can be paid? Stop loss carriers often purchase reinsurance for several reasons—the most common being to mitigate their liability on catastrophic claims (those exceeding $2 million).
• How many days does the carrier average for claim reimbursements?
• Does the carrier offer true advance funding of claims in excess of the specific deductible to facilitate cash flow for your clients? If so, is this advance funding available for the duration of the contract, including the last 30 days of the policy?
• Are your clients able to find out—in advance of a reimbursement request—how the carrier will reimburse a stop loss claim?  This could help the employers clarify their intended Plan Document coverage for experimental/investigational treatments or procedures involving new technologies.

An experienced carrier with knowledgeable claims staff and efficient processes will help ensure your clients’ self-funded plans work as intended.

Stay tuned for our next post as we close out this series with underwriting practices. Is the policy renewal-friendly?

Stop Loss in 2018: cost vs. value; striking the right balance for your self-insured clients (part 2)

Part 2: Contract quality—inclusive vs. exclusive

Are your clients exposed to coverage gaps between their plan document (from which the administrator determines claim eligibility) and the stop loss policy?

Many top-tier carriers have inclusive contracts designed to eliminate these gaps. Typically, these contracts are not the lowest cost, and we tend to see a correlation between contract strength and industry tenure. In contrast, exclusive contracts can contain 18 or 20 exclusions or limitations. These contracts are designed to mitigate liability and allow the carrier to deny a claim reimbursement. It's no surprise to see these carriers lead with low pricing.

With the significant growth in the stop loss market—an industry estimated to be $14 billion to $17 billion annually¹—we are seeing some new carriers enter the marketplace. Without significant blocks of business capable of absorbing surges in large claim incidence and severity, it’s not uncommon to see new-to-market carriers file their contracts with several "gotchas."

To avoid falling into a gap situation, here are some questions to ask carrier finalists: 

• Does the contract include an exclusion for claims in excess of "usual and customary"?
• Does the contract have an actively-at-work requirement? If so, employees who are on disability or other types of leave at contract inception may not be covered under the stop loss policy.
• Does the contract define "medical necessity" or "medically necessary"? If so, claims may be denied if the carrier deems them not medically necessary. How the carrier defines medical necessity is critical in determining gap potential.
• Is the plan document used to determine whether expenses are eligible for reimbursement? This is often referred to as "mirroring" the plan document and may be offered as a "mirroring endorsement."
• Does the contract exclude expenses associated with medical tourism?
• Does the contract exclude medical review and case management fees?
• Does the contract exclude or limit claim reimbursements in the event the administrator loses a PPO discount or other discount?

Consultants who have witnessed a claim denial (when the employer ends up holding the bag) can spot exclusionary contract language and recommend carriers that eliminate gaps for their clients. Be sure to ask these questions to avoid gaps in your clients’ coverage.

In our next post, we’ll discuss why cash flow is king! 

 

^{1 “}2016 employer stop-loss market” – A Milliman survey, June 2017.

 

 

Stop Loss in 2018: cost vs. value; striking the right balance for your self-insured clients (Part 1: Our stop loss market)

Part 1: Our stop loss market

Because of the Affordable Care Act (ACA), more employers are opting to self-fund their medical programs than ever before. In fact, 60% of all employer groups now self-fund.¹

This growth in the market has recently enticed several new players to the stop loss space. The field now includes established direct-writing carriers, new-to-market direct writing carriers, and managing general underwriters (MGUs).

So, what are the most important variables to consider when choosing a stop loss partner for a self-insured medical program? Three primary factors are:

1. Contract quality: Is the contract inclusive or exclusive by design? Mind the gap(s)!
2. Claims expertise and service: How efficient and proactive is your carrier partner? Cash flow is king!
3. Underwriting practices: Is the policy renewal-friendly? Underwriting culture can introduce volatility into the pricing of your self-insured program.

Self-funding a medical plan has many advantages, but along with that comes many responsibilities. Partnering with a best-in-class stop loss carrier can help ensure that the self-funded plan runs as intended and that there are no surprises along the way.

In our evolving stop loss market, are your clients getting what they pay for? Find out more in our next post.

¹ The Kaiser Foundation and Health Research & Educational Trust, “Employer Health Benefits 2015 Annual Survey,” 2015.

Need help to close the coverage gap?

 

 

 

A fixed-payment gap plan can be a great option for employees in a high-deductible health plan. But your clients may have a hard time explaining these benefits to their workforce. That’s why we’ve developed this new video to help illustrate what a gap plan is and how it can provide financial relief by helping employees with out-of-pocket costs—all in under two-and-a-half minutes. To learn more, contact your Symetra representative.