Stop Loss Insurance

Steadfast protection that weathers any storm

Our Stop Loss Insurance helps self-funded employers lessen the impact of devastating medical claims through flexible contracts, customizable plans and a consultative, client-focused approach.

We support self-funded groups down to 100¹ lives and individual deductibles down to $25,000 — to help keep costs in check and predictable for employers and their employees. Many of our Stop Loss features are standard including plan mirroring, individual advanced funding and ASO expedited reimbursement. Several years ago, we developed a unique approach to underwriting, managing and renewing cell and gene therapy claims to support our customers when they need it the most (see “Cost Containment” tab to learn more).

Among the top 3 direct writers of Stop Loss in the U.S.²

Whether you’re carving out Stop Loss for the first time or you’re an experienced client looking for cost containment solutions, we can help. We’ll be by your side every step of the way.

• Flexibility – Whether you’re incorporating PPO networks, reference-based pricing plans, hybrid plans, direct contracts, carve-outs for certain treatments or conditions, or other custom solutions, we are here to help.
• Streamlined claims process – Along with a premier claims team, employers receive individual advanced funding or ASO expedited reimbursement, which is standard, and optional monthly accommodation for aggregate coverage is available.
• Cost Containment programs – We can assist with managing claims costs, as our experienced team will help connect employers to premier networks and vendors for needs such as transplant or cancer care. We may also provide additional credit and coverage for point solutions and pharmacy solutions an employer implements.

Choose between two approaches to Stop Loss: unbundled or bundled

Unbundled or carved-out Stop Loss allows you to choose the optimal vendors with the goal of finding the greatest cost savings and benefits for your specific plan. We can lock in quotes with nine months of complete claims information for the current policy year and build a multi-year plan intended to help keep your costs down and your employees covered.

Choosing the unbundled approach may also lead to improved Stop Loss terms and conditions. More advantages to unbundling include:

• Greater flexibility – Employers can select a Stop Loss policy that best fits their needs without being tied to the administrator’s offerings
• Potential cost savings – Employers can select the most cost-effective Stop Loss policy and administration services separately, which can help to encourage savings
• A second set of eyes – We can help employers look at and “audit” their highest dollar catastrophic claims

How employers benefit from an unbundled plan:

Cost Containment programs⁷ to help mitigate costs and maximize savings

Our team of clinicians strive to achieve savings for our clients with large case management assistance, while providing a seamless experience to members. Employers can get help managing high-dollar conditions from transplants, high risk pregnancy and burns or multiple trauma — to blood clotting drugs, hospitalizations lasting seven or more days, and more.

• Auditing high-dollar claims
• Reviewing high-cost diagnoses, drugs, therapies, and precertification/large case management notifications for possible intervention
• Proactively monitoring industry trends and new treatments

How we can help you and your employees

Vendors and programs

Our dedicated Cost Containment team will ensure employers are connected to the resources they need. All of our Cost Containment programs are included with our Stop Loss coverage, voluntary on a case-by-case basis and include:

• Competitive vendor fees that are a fixed percentage of savings
• Vendor fees reimbursed to clients within the applicable Stop Loss claim
• An experienced Cost Containment team to meet your individual needs

Program details

• Transplant networks: We have agreements with multiple leading transplant networks and national centers of excellence networks — and offer extra-contractual negotiations for out-of-network facilities. Access to these networks and services can help reduce an employer’s financial risk.
• Specialty pharmacy: Specialty pharmaceuticals can be costly. This program through our third-party vendor is focused on clinical and bill review and claim negotiations for complex and chronic conditions requiring specialty, biotech, infusions and other medical products. A pharmacist is available to review and negotiate these specialty needs.
• Cell and gene therapy management: We work with our third-party vendors to offer solutions that help payers manage the immense cost, high-risk and intricate processes associated with treating rare, complex and costly medical conditions.
• Renal and dialysis management: The treatment of chronic kidney disease, renal dialysis and end-stage renal disease can drive some of the highest costs for self-funded medical plans.⁸ Our third-party vendor offers an extensive network of 3,000 outpatient dialysis facilities — and provided itemized bill review and negotiations for out-of-network facilities. Significant discounts on dialysis, medications and dialysis related services — coupled with coordinated care — helps control costs and enhance overall patient care.⁹
• Claim review and negotiation: Through our third-party vendors, we provide bill review, negotiation and documentation of settlement for both in-network and out-of-network claims. Our highly experienced claim negotiation vendors determine what amounts are within industry standards and where negotiation would be most effective. Once the claim negotiators have come to an agreement, a contractually binding discount settlement is signed by the provider to eliminate disputes and/or balance billing to the patient or employer group.
• Cancer treatment: We have multiple options to help cost contain high-cost cancer claims. We offer access to premier network rates at nationally recognized facilities and our vendors offer discounts with Cancer Treatment Centers of America (CTCA).

Cancer Treatment Centers of America (CTCA) are not affiliated with the Voya® family of companies.

We’re always looking for ways to leverage innovation to help self-funded employers. Here are two of our latest solutions — with more in development:

Stop Loss Edge

Stop Loss Edge is an innovative way to take advantage of self-funded health plan coverage, offering a pooled approach to renewals and rewards. Designed for mid-market plan sponsors with 100¹ to 500 employees, it offers opportunities for long-term stability and access to rewards for profitability of both group and pool results.

Eligibility Fast Pass

Eligibility Fast Pass is a process that allows us to utilize basic eligibility information provided via a “preferred census” to review initial claims. This service is available for all employers with our Stop Loss coverage. When used in conjunction with the regularly required census, the additional “preferred census” data points enable us to review most claims without pending the initial claim, sending a request for eligibility and awaiting the information to be provided.¹⁰