By Bill Rusteberg
Lasers are to die for. We should love them! I’d rather take a chance than pay an upcharge for something that may or may not happen.
Taking it a step further, why have stop loss anyway? Structure the plan like E&O group offerings are made……….Aggregate overall limit that when reached the plan terminates and converts to ICHRA for immediate pick up of coverage.
SAMPLE PLAN DOCUMENT LANGUAGE
ANNUAL AGGREGATE POLICY MAXIMUM
The Annual Aggregate Policy Maximum is the maximum total amount payable by the Plan for all covered claims and expenses incurred by all covered participants and dependents during the Plan Year. For each Plan Year beginning on January 1 and ending on December 31, the total liability of the Plan for all eligible medical, prescription drug claims and expenses shall not exceed the Annual Aggregate Policy Maximum subject to adjustments based on enrollment and plan design. The Annual Aggregate Policy Maximum is established at the beginning of each plan year based on the following formula: Expected Claim X 1.25 + Fixed Costs. (Example: Expected Claims = $5,500,000 X 1.25 = $6,875,000 + $500,000 Fixed Costs – $7,375,000 Annual Aggregate Policy Limit).
This limit applies separately from any individual stop-loss (ISL) limit that may apply to specific high-cost claimants.
The Plan may cease payment of claims for the remainder of the Plan Year.
Stop-loss insurance coverage (if applicable) may reimburse the Plan Sponsor for aggregate claims paid above the maximum, in accordance with the terms of the stop-loss policy;
Covered participants may continue to receive benefits as described in the Plan, provided the Plan remains active and funded.