Stop-loss insurance protects a self-funded employer from large claims. Specific stop-loss caps cost per individual, while aggregate stop-loss caps total plan claims for the year.
Ask specifically about a no-new-laser provision, a cap on renewal increases, renewal without a new signed disclosure, and how run-out or terminal coverage depends on renewing. Each is a separate promise with its own conditions, and none should be assumed from another.
Under ordinary reimbursement, yes: the plan pays the claim and then files for reimbursement. Options such as specific advance funding (coordinated reimbursement) and monthly aggregate accommodation can ease that cash-flow strain, if the policy includes them.
It is an extra layer the employer keeps above the ordinary specific deductible: claim dollars over the specific deductible go into a fixed-dollar fund the employer pays, and reimbursement starts only after that fund is used up. It lowers premium in exchange for more risk and is not the same as aggregate stop-loss.
The plan still owes the benefit to the employee, and the employer pays it without reimbursement. That is why the stop-loss policy should mirror the plan document, and any plan change or exception should be approved in writing by the stop-loss carrier first.
Run-in claims were incurred before the new policy started but paid during it; run-out claims were incurred during a policy but paid after it ends. If the old policy has no run-out and the new one has no run-in, a large claim incurred in December and paid in February can be covered by neither.
Terminal liability is an option that extends specific and/or aggregate stop-loss for a run-out period after the policy ends, commonly 3 or 6 months, so claims incurred before the end and paid shortly after are still insured. It usually must be elected before the contract ends.
The first number is the months of incurred claims the policy recognizes and the second is the months in which those claims must be paid. A 12/12 covers claims incurred and paid in the same 12 months, a 12/15 or 12/18 adds 3 or 6 months of run-out, and a 24/12 adds 12 months of run-in for claims incurred before the contract started.
The insurer starts from expected claims and adds a corridor, a percentage set in the quote, then usually turns that into monthly aggregate factors multiplied by actual monthly enrollment. The employer pays eligible claims up to that total before aggregate reimbursement begins.
A laser is a stop-loss term that gives one known high-cost person a higher specific deductible (or an exclusion) under the employer’s policy. It changes how much of that person’s claims the employer funds, not the employee’s benefits, and the plan still may not cut that person’s eligibility or charge them more because of their health.
Stop-loss insurance protects a self-funded employer from catastrophic claims. Specific (individual) stop-loss caps the plan’s exposure to any one person’s claims above a set deductible; aggregate stop-loss caps total claims for the whole group above an expected threshold.