Individual Stop-Loss Program Clause Samples
The Individual Stop-Loss Program clause establishes a financial protection mechanism for employers or plan sponsors by setting a maximum limit on the amount they are responsible for paying for claims incurred by any single covered individual. In practice, once an individual's eligible claims exceed a predetermined threshold within a policy period, the stop-loss insurer reimburses the plan for the excess amount. This clause is essential for mitigating the risk of catastrophic claims, ensuring that a single high-cost medical event does not jeopardize the financial stability of the health plan or employer.
Individual Stop-Loss Program. PacifiCare shall provide Individual Stop-Loss (“ISL”) protection in order to limit Medical Group’s financial risk for Medical Group Services (“ISL Program”). The ISL Program is designed to limit Medical Group’s financial responsibility for Medical Group Services to a specified dollar amount per Medical Group Member per calendar year (“ISL Deductible”), while encouraging Medical Group’s continuing involvement with Medical Group Member’s care by sharing a portion of the financial responsibility for Medical Group Services which exceed the ISL Deductible (“ISL Coinsurance”). PacifiCare shall charge a premium (“ISL Premium”) as consideration for the ISL Program. The ISL Deductible, ISL Coinsurance and ISL Premium for Medical Group are specified in each Product Attachment. Notwithstanding any other provision of this Agreement, PacifiCare may amend the ISL Deductible, ISL Coinsurance and ISL Premium on an annual basis effective at the beginning of any calendar year by providing sixty (60) calendar days prior written notice to Medical Group. During each year of this Agreement, should Medical Group fail to provide PacifiCare with timely evidence of ISL protection consistent with regulatory requirements. PacifiCare shall assign such coverage to Medical Group and deduct the then-current ISL Premium from the Medical Group’s Capitation Payments as further described in each Product Attachment. For Medical Group Services which exceed the ISL Deductible, PacifiCare will pay Cost of Care, less the Medical Group’s ISL Coinsurance amount, subject to the Medical Group’s compliance with the procedures set forth in the Provider Manual and the provisions of this Section set forth below.
Individual Stop-Loss Program. The ISL Deductible and ISL Premium for the Secure Horizons Health Plan initially will be:
(i) ISL Deductible - Not Applicable per Secure Horizons Member per calendar year.
(ii) ISL Premium - Not Applicable of Secure Horizons Revenue.
Individual Stop-Loss Program. The ISL Deductible and ISL Premium for the PacifiCare Commercial Plan initially will be:
(i) ISL DEDUCTIBLE - Non-Applicable
(ii) ISL PREMIUM - Non-Applicable
Individual Stop-Loss Program. The ISL Deductible and ISL Premium for the PacifiCare Commercial Plan initially will be:
(i) ISL Deductible - Not Applicable per Commercial Plan Member per calendar year.
(ii) ISL Premium - Not Applicable of Commercial Plan Premium.