Stop-loss is vital to the self-funded marketplace, and for good reason – because catastrophic claims can bankrupt an employer in the blink of an eye. Not all is well in the land of stop-loss, however, as forces – both internal and external – conspire against stop-loss carriers. Regulators, fearing the impact self-funded adverse selection may have on PPACA exchanges seek to eliminate self-funding by striking at stop-loss. Meanwhile, many will attest that some stop-loss carriers have taken a more heavy handed approach to cost containment. There are different types of carriers and MGUs in the marketplace, with varying attitudes toward discretion, plan language, bill auditors, caps on payable amounts, and many other aspects of a reinsurance arrangement that can be the difference between being able to comfortably self-fund a health plan and being forced into the fully-insured market.

Thank you for joining The Phia Group’s legal team on Tuesday, January 19, 2016, as they provided first-hand insight into the self-funded market’s reliance on stop-loss and threats to that industry, including what TPAs and brokers should look for – and look out for – when advising health plan sponsors regarding stop-loss options.

As employers look to self-fund with increasing frequency, expectations that brokers, vendors, and third party administrators will take on more binding authority are trending as well. Cases where an entity is held liable for failing to uphold a responsibility it didn't intend to adopt are consequently on the rise as well. These recent cases impact how you are (or at least should be) handling claims.