ENGAGING SBR

• Requested Effective Date

• Detailed information on third party administrators, provider networks, pharmacy benefit managers, case managers, utilization review vendors and things being considered (i.e. reference based reimbursement programs, medical bill review programs) as part of the overall self-funded health plan evaluation process so we can make sure we are getting the markets to appropriately price out the stop-loss insurance.

• Regarding the underlying plan design, if there are changes being considered as part of the overall self-funded health plan evaluation process, we would like to receive these details to make sure we are getting the markets to appropriately price out the risk transfer arrangement.

• Requested Due Date

• Requested Commission Levels

• Employee Census File – For the employee census file, we will need to get a detailed report with the following required information for all employees regardless of whether they are enrolled or not:

  • Unique employee ID

  • Gender (Required)

  •  Home zip code (Required)

  • Date of birth (Required)

  • Employment Status (e.g. Active, Retiree, COBRA, leave of absence, on disability) (Required)

  • Date of hire

  • Date of termination (for active COBRA participants only)

  • Current Medical Plan Election (Required if more than one plan is offered)

  • Current Medical Coverage Tier (Employee Only, Employee and Spouse, Employee and Child(ren), Family) (Required)

Please make sure the employee census file includes all eligible and enrolled employees regardless of status (i.e. active, retirees, COBRA participants, employees on disability and employees on leave of absence).

• Copies of current summary plan descriptions or detailed benefit summaries for each line of coverage including:

• Medical Coverage

• Prescription Drug Coverage (if included in the stop-loss coverage)

• Dental and/or Vision Coverage (if included in the stop-loss coverage)

• Copy of the current individual and aggregate stop-loss policy. Not applicable if the group is fully insured. At a minimum, policy should include effective date, contract basis, individual stop-loss deductibles, aggregate stop-loss attachment factors, premium rates, details on any separate lasered deductibles/individuals, aggregate stop-loss corridor, any endorsements or riders.

• For the coverages currently included in the current stop-loss contract (i.e. medical, prescription drug), we will need paid claims and enrollment counts for each of the last two full plan years as well as the current plan YTD. If two years of data is not available, we will need at least the last full year plus the YTD data. For example, if the plan year starts January 1st, we will need paid claims and enrollment by month for the following time periods:

   

  January 1, 20XX – December 31, 20XX

  January 1, 20XX – December 31, 20XX

  January 1, 20XX – Current

   

• Large loss report for the same, corresponding, time periods above. The large loss report should include individual claimants with claims in excess of the lesser of $50,000 or 50% of the current deductible level. At a minimum, the report should include the amount of paid claims and the primary diagnosis. Please include the following additional information if available: secondary diagnosis, prognosis, relationship, active or termed and whether the claimant is currently in case management.