What is the Purpose of a Stop-Loss Provision in a Health Insurance Plan?

All you need to know about a Stop-Loss Provision in a Health Insurance Plan.

As its name suggests, stop-loss insurance is a product that enables your company to control expenditures for employee medical costs consistently. It’s a specialized form of insurance meant to guard self-insured firms against significant losses. Due to constantly growing prices and increased employee unhappiness with high payments and deductibles, many firms of all sizes have decided to do away with traditional group health insurance policies.

As an alternative, companies self-insure their medical benefits plans. Some businesses manage self-insurance by creating a special fund to cover employee and family medical expenses. Others pay their payments with their current cash flow. The transition to self-funding may have just a small number of employees. Getting medical care still follows the same procedure. Instead of billing a third-party insurance company, the provider secretly submits a bill to the patient’s employer.

However, the health plan’s terms may alter based on what and how much the employer chooses to cover. Self-funded plans are exempt from state mandates, giving businesses more freedom to design employee-specific insurance. Workers may also end up with more provider alternatives because they wouldn’t be constrained to the predetermined network of an insurance company. Health insurance policies are designed to cover all the insured’s medical expenses. These policies have many clauses, one of these being a stop-loss provision.

What is a Stop-Loss Provision?

In essence, stop-loss insurance is a measure used by employers to protect themselves from the possibility of severe financial loss. Losses are limited to a particular level, and the stop-loss insurance is responsible for paying any expenses that exceed the stipulated restrictions.

A stop-loss provision is a clause in the health insurance policies with a deductible and a co-insurance arrangement that says that policyholders do not have to pay anything more from their pocket once the expenses have reached the specific limit already indicated in the policy. Simply put, it limits claim coverage for losses to a particular amount. It ensures that any catastrophic losses do not exceed the coverage limit and drain the financial reserves of a self-funded plan. It assumes the boundary of the exact amount, after which the insurance company will pay all the medical expenses. It’s like limiting the deductible you will pay for your medical expenses.

For example, in a policy with a $3500 stop-loss provision, the insured is no longer required to pay any more as part of their coinsurance percentage after they have spent the entire amount of $3500 in out-of-pocket expenses, i.e., deductibles. It is also known as out-of-pocket stop-loss insurance.

 Image Source: Health Insurance Providers
Image Source: Health Insurance Providers

Employers use stop-loss insurance to determine the coverage for risk against a high value of claims. It comes with a maximum level for allegations, and when the maximum threshold exceeds, the employer will no longer make payments and even go on to receive some reimbursements.

Stop-loss insurance can be added to an already purchased insurance policy or purchased independently. The threshold for the maximum claim limit is calculated based on a certain percentage of projected costs, also known as attachment points, which are usually 125% of anticipated claims for that year.

A stop-loss insurance threshold is usually variable instead of fixed. The threshold fluctuates according to the percentage of an employer’s current employees. The unstable point is based on an essential component in calculating a stop-loss level, that is, an aggregate attachment.

Like all high-deductible plans, most stop-loss insurance policies will also have relatively low premiums. It is because the employer is usually expected to cover over 100% of the value of claims they receive themselves.

Stop-loss provisions in health insurance are provided for the company’s employees through a self-insured plan that they often subscribe to protect themselves from catastrophic or massive claims. Usually, there is an annual limit set for stop-loss amounts for each participant it covers, along with an aggregate amount charged for each policy year. The premium is then calculated for each month of the year. The compensation for the participants of the stop-loss amount is then based on the number of participants, the age of the participants, and various other information.

Moreover, the coinsurance requirement for any stop-loss insurance carriers will continue until you reach the stop-loss point, after which you will not be responsible for paying 20% of an indefinite amount like you would have had to before reaching the stop-loss point. The stop-loss threshold for each insurance company varies and can be reached at any amount. It is also a contributing factor to the policy’s premium. Your premiums are likely to be low the higher the stop-loss is. So if you want to keep your tips low, you should have a high stop-loss, high deductible, and low coinsurance.

Specific stop-loss protection

This kind of insurance, sometimes called “individual stop-loss,” covers a person’s risk against high-value claims. Specific stop-loss insurance shields businesses against a massive lawsuit from a particular person rather than offering protection against an unusually high number of shares.

Stop-loss insurance in total

Instead of covering individual claims during a plan year, this kind of stop-loss insurance pays the total shares of all insured members. A contractual period’s worth for all certified members. A contractual period’s value of losses is constrained by aggregate coverage. The insurer will pay the business back if the total amount of claims exceeds the aggregate limit. Some self-funding insurance programs place the whole burden of paying for medical expenses on the shoulders of employers. However, with a stop-loss component, companies are safeguarded from abnormally high individual claims and claim frequency for all insured employees.

How does stop-loss insurance work?

Stop-loss insurance is a financial and risk management instrument corporations use; it is not health insurance. It’s unrelated to a company’s personnel in any way. While self-insurance might reduce costs, the employer is solely liable for qualified medical expenses without a health insurance provider. That’s not a concern as long as the workers stay healthy. However, if many people get sick, say from the most recent flu virus, or even if just one person is diagnosed with cancer, medical expenses might quickly exceed the company’s means of support.

In the worst-case situation, such can result in the closure of an employer. If the employee’s medical costs are not paid, the employer may be liable in court, which would have similarly severe effects. The employee’s out-of-pocket expenses under stop-loss insurance are restricted to a predetermined sum. The stop-loss policy pays any extra expenditures if costs go beyond that cap. It’s crucial to remember that while this coverage is provided through reimbursement, employers are still liable for making the first payment. Furthermore, it’s vital to remember that stop-loss insurance frequently has coverage restrictions.

While most businesses “settle up” with their stop loss insurance after the policy year, certain employers can lessen their potential financial load by arranging monthly payments instead of the annual sum. The drawback is that the employer will be responsible for making up the difference if those payments have surpassed absolute necessity by the end of the year.

 Image Source: bagira22/iStock
Image Source: bagira22/iStock

Two kinds of stop-loss insurance assist in reducing employer liability:

  • Individual or specialized coverage safeguarded Your business from significant, catastrophic claims. When a single person’s qualified medical claims total more than the predetermined cash amount for the policy year, this insurance begins to pay out.
  • Your business is protected from many high-value claims or an unexpectedly large overall claims volume by total claims coverage, often known as aggregate coverage. When an employer’s expenses for all employee medical claims surpass the predetermined cap for the contract year, this insurance takes effect.

Only one sort of coverage needs to be obtained. However, individual and collective coverage is equally significant to most companies. Because the use of health insurance is so unpredictable, you want the most financial security possible. Other expensive chronic diseases might affect employees and their dependents besides a large viral epidemic or a single cancer diagnosis.

They could need an organ transplant or possibly urgent surgery. Accidents happen to people, and they can have grave medical repercussions. Premature newborns may stay in the hospital for weeks or even months. Furthermore, cutting-edge medical technology and treatments are expensive and steadily growing.

Risk is minimal if workers and their families remain healthy and the year’s total number of medical claims is low. However, unforeseen medical expenses can quickly reach hundreds of thousands of dollars. It can harm a company’s profitability capacity by exhausting its self-insurance cash reserve or severely limiting cash flow. Although there is always a possibility that it might have effects throughout the entire organization, it tends to be more evident with smaller businesses.

Consider the following figures:

  • Over 85% of self-insured businesses with up to 5,000 workers purchase stop-loss coverage.
  • 61% of Americans who get health insurance via their workplace work for self-insured organizations.

Aggregate Stop-Loss Insurance Calculations

The aggregate affection associated with a stop-loss plan is calculated as follows:

 Image Source: ConnectiCare
Image Source: ConnectiCare
  • Step 1: The employer and stop-loss insurance supplier will estimate the average dollar value of monthly claims expected by an employee. Depending on the employer’s estimate, it often ranges from $200 to $500
  • Step 2: Assuming that the stop-loss plan has a value of $200 which would then be multiplied by the stop-loss attachment multiplier. It ranges from 125% to 175%. The monthly deductible per month per employee would be $250, using a claims estimate of $200 and a stop-loss attachment multiplier of 25. ($200 x 1.25 = $250).
  • Step 3: This deductible must be multiplied by the employer’s monthly plan enrollment. Supposing an employer has 100 employees in the first month of insurance, their total allowable would be $25,000 for the month ($250 x 100).
  • Step 4: Enrollment can typically vary per worth, so the aggregate stop-loss coverage will have a monthly or annual deductible.
  • Step 5: The amount an employer has to pay with a monthly deductible could change every month. However, the amount the employers would have to pay for the annual deductible would be summed for the year. It is also usually based on estimates from the initial month of coverage. Many stop-loss plans offer a yearly deductible slightly lower than the total sum of deductibles over 12 months, i.e., a year.

Now that we are clear on the objective of a stop-loss provision in a health insurance plan, it would be easier to buy a health insurance policy and read the fine print to figure out all you need to know about the various clauses in the policy.


A stop-loss supply is a specific article in a health insurance policy with a deductible and coinsurance arrangement that specifies that once the insured’s out-of-pocket expenses reach the predetermined amount or limit specified in the policy, they are no longer required to pay any percentage of the medical costs. Without this clause, the insured would always be responsible for some of their medical expenses.

John Otero

John Otero

John Otero is an industry practitioner with more than 15 years of experience in the insurance industry. He has held various senior management roles both in the insurance companies and insurance brokers during this span of time. He began his insurance career in 2004 as an office assistant at an agency in her hometown of Duluth, MN. He got licensed as a producer while working at that agency and progressed to serve as an office manager. Working in the agency is how he fell in love with the industry. He saw firsthand the good that insurance consumers experienced by having the proper protection. John has diverse experience in corporate & consumer insurance services, across a range of vocations. His specialties include Major Corporate risk management and insurance programs, and Financial Lines He has been instrumental in making his firm as one of the leading organizations in the country in generating sustainable rapid growth of the company while maintaining service excellence to clients.

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