Stop Loss / Self Insured Coverage
Specific stop loss is available for 50 or more covered employees. It is offered as a stand-alone product, or in addition to our carriers’ aggregate stop loss coverage.
Simple Self Funding
Simple Self-Funding offers Employers that are currently Fully Insured to Self Fund their Health Benefits without high attachment point risk or renewal lasering concerns. This product offers commissions to the broker at 5% and are based off of the equivalent premium. Please review the product highlights below:
• Underwritten by Fairmont Specialty on behalf of United States Fire Insurance Company*
• No Lasering – First Year or Renewal
• Maximum monthly and annual cost for the Plan Sponsor
• No claims history required for underwriting currently fully insured groups
• ERISA program, no state mandates
• Group Self-Funded program
• Fully integrated cost containment
• Fully transparent rates, costs and expenses
• Competitive pricing
• HSA compatible plan options
• Specific and Aggregate Stop Loss Coverage
• 12/18 Contract (claims incurred in the 12 month contract year and paid in the contract year
or six months following)
• $25,000 Standard Specific Deductible
• Simultaneous Specific Reimbursement included on all accounts at no cost
• Advanced Monthly Accommodation included on all accounts at no cost
• 15 Employees (maximum group size is 75 lives)
• 75% Participation of Eligible Employees
• 50% Employer Contribution towards Employee cost
• True Employer/Employee relationship
Life, ADD, STD and LTD
• Available to groups of 15 or more employees.
• Flat benefits amounts or salary multiples.
• Dependent Group Life available.
• Non-contributory plans: Employer pays.
• Voluntary/Contributory plans: Optional or Supplemental plans; Employee pays.
• Include waiver of premium/conversion.
• Available for groups of 25 or more employees.
• Benefit percentages: 50%, 60%, 67%.
• Benefit maximums: up to $25,000 per month.
• Elimination periods: 90, 180 or 360 days
• SS Integration: Primary, Full Family, 70% All Source, Backdoor.
• Own occupation definitions: 2 to 5 years, to age 65.
• Benefit durations: 2 to 5 years, to age 65.
• Available to groups of 25 or more employees.
• Benefit percentages: 50% to 70%.
• Benefit maximums: up to $1,500 per week.
• Elimination periods: 0, 7, 14 or 30 days.
• Benefit durations: 13, 26 or 52 weeks.
Commercial Group Intermediaries offers a fully insured, first dollar organ and tissue transplant carve out for self funded groups. This remarkable benefit is encompassed in an admitted stand alone policy that can attach to any plan document, regardless of the stop loss carrier. The coverage begins at patient evaluation and extends 365 days post transplantoperation, and pays 100% of all covered transplant-related physician, hospital, and drug expenses when in network. A shorter benefit period is available.
- As many as 40%-50% of all lasers imposed on self funded groups are due to transplant exposures.
- The average waiting time for a solid organ is over a year. As a result, transplant patients usually jump over stop loss contract years, thus becoming magnets for imposed lasers or rate increases.
- SMALL SELF-FUNDED GROUPS GENERALLY CANNOT INTERNALLY FUND A TRANSPLANT EXPOSURE AS ECONOMICALLY OR EFFICIENTLY AS THROUGH OUR CARVE OUT POLICY.
- Bone Marrow
- Stem Cell
- 100% coverage on all major transplant types from first dollar to $1 million life maximum.
- 100% coverage for NCI Phase Trials III and IV for adults, Phases I through IV for pediatrics (this is a much more liberal coverage of experimental than most plan documents allow).
- No deductibles for patients when in-network.
- Liberal expense allocations for patients traveling to distant centers of excellence.
- Benefit period covers from time of patient evaluation through 365 days post transplant, and includes hospital, physician and pharmaceutical expenses.
- Direct payment by Medical Excess to providers, no cash flow issues for the employer.
- Complete medical management and coordination of the patient with on-staff RNs.
- Average cost of about $8.00 PEPM, a far less expense than the cost of a laser.
- Contributes budget predictability and stability to Stop Loss rates.
- 5% commission
- Many stop loss carriers give a 2% to 10% credit on the specific stop loss for the transplant carve out, based on stop loss specific deductible.
- TPA Partners are waived of group minimum size, thus becoming a competitive differential for groups looking for this coverage.
- Extensive marketing assistance afforded to the producer from CGI to help sell the program.
- A group can be eligible for this coverage regardless of their stop loss carrier, as long as they meet minimum enrollment requirements.
- High renewal persistency among groups with transplant carve out.
- Carrier management of transplant exposures allows administrator to redirect internal clinical resources to more chronic problems.
- Unions and Associations often cap transplants at $250K and less, rendering it a less valuable benefit.
- Large, completely self funded groups. Many don't want to sustain a single catastrophic hit such as Transplants and may have a high frequency issue.
- Groups that have experienced a transplant exposure in the past or groups where a laser has played havoc with their stop loss insurance.
- Groups that "have never had a transplant exposure". The best time to buy transplant insurance is when the group is completely clean of exposures.
Welcome to Medical Tourism.
For those of us who have not heard the term “Medical Tourism” it is very possible you will in the near future. Segments on 60 Minutes, Nightline, and articles in the Wall Street Journal have all indicated that Medical Tourism’s competitive pricing coupled with quality care will continue to push domestic medical needs to foreign markets. Medical Tourism is here to stay and is growing at an unpredicted rate. In 2008 projected medical travel was expected to reach 750,000 and in 2011 to exceed 9,000,000 which will revolutionize medical delivery in our country and the international sector. Hospitals in the international community and are JCI accredited and will compete with US Hospitals for patients on a global basis.
Why Medical Tourism?
In today’s self insured market Medical Tourism is an alternate choice and can be added to the Plan Document in a passive manner. How? By offering incentives to the employee in the form of waiving deductibles, coinsurance, and the out-of-pocket maximums and also offering spousal travel. The employer also benefits because his reimbursements for stop loss are less as illustrated below:
|Procedure||U.S. Average||International Average|