Describes two aspects in insurance. The policyholder may be protected by a ceiling on the amount that must be paid out-of-pocket for deductibles and co-insurance for covered services and allowable charges in a policy year. A health plan may purchase insurance to protect the plan against costs that exceed specified levels.
An insurance policy purchased by a self-insured employer to reimburse the employer for claims paid on behalf of covered employees in excess of certain amounts. SUMMARY PLAN DESCRIPTION (SPD) The evidence of coverage required under federal law to be issued by a self-insured employer to its employees.
Insurance offered to medical groups and hospitals that hold managed care contracts. This insurance covers the policyholder in case its patients suffer catastrophic medical conditions beyond the standard and customary.
This is a type of reinsurance which can be taken out by a health plan or self-funded employer plan. The plan can be written to cover excess losses over a specified amount either on a specific or individual basis, or on a total basis for the plan over a period of time such as one year.
Insurance purchased by an insurance company or health plan from another insurance company to protect itself against losses. A type of insurance coverage that enables provider organizations or self-funded groups to place a dollar limit on their liability for paying claims and requires the insurer issuing the insurance to reimburse the insured organization for claims paid in excess of a specified yearly maximum. Reinsurance purchased to protect against the single overly large claim or the excessively high aggregated claim during a set period. Providers when purchasing Malpractice, Workers Comp and Liability coverages, may also use Stop Loss. Also see Reinsurance and Specific Stop Loss.
A contract established between a self-insured employer and an insurance provider providing for carrier coverage if a claim incurred exceeds a specified dollar amount over a predetermined period of time.
Insuring with a third party against a risk which an MCO cannot financially and totally manage. For example, a comprehensive prepaid health plan can self-insure hospitalization costs with one or more insurance carriers.
