Att C6 - 2021 Revised Stop Loss Contract Medica.pdf

This is a Stop Loss Contract document for Medica, a health insurance provider, revised for 2021 and used by a state or local consortium for employee health benefits coverage. The contract outlines stop loss insurance services designed to protect self-insured health plans from catastrophic claim costs by establishing individual and aggregate deductibles. The document addresses enrollment parameters, claims processing procedures, and coverage specifications for participating employees and dependents. The contract establishes mechanisms for claims management, fund accounting, and actuarial review to ensure the stop loss coverage operates according to specified thresholds and protection levels. The contract term and renewal provisions would be detailed within the agreement structure, along with any performance metrics and service level requirements expected from the carrier during the coverage period.

The pricing structure for this stop loss contract is based on actuarial calculations tied to the specific risk profile and claims history of the covered group, with premiums typically calculated per employee or as a percentage of expected medical claims. The contract likely includes provisions for rate adjustments based on claims experience and renewal rating methodologies. As the incumbent carrier, Medica would maintain ongoing service obligations including claims administration, reporting, and compliance with state insurance regulations. The funding source derives from employer and employee contributions to the self-insured health plan, with Medica receiving premium payments in exchange for assumption of costs above the established deductible thresholds. Key considerations include adherence to stop loss policy limits, coordination with the plan's third-party administrator if applicable, and compliance with applicable state and federal health insurance regulations regarding coverage standards and claims payment timelines.