As with all proposed federal healthcare changes, 90 Degree Benefits is closely monitoring Trump’s Great Healthcare Plan to understand how it could impact employers across the U.S., particularly those sponsoring self-funded and level-funded health plans.

Below is a practical breakdown of the proposal’s key components and what employers and brokers should be watching.

Key Components Relevant to Self-Funded Health Plans

Most Favored Nation (MFN) Drug Pricing and Expanded OTC Access

The proposal builds on Most Favored Nation (MFN) drug pricing concepts previously explored by the Trump Administration, aiming to reduce prescription drug costs by tying prices to international benchmarks.

It also expands over-the-counter (OTC) access for certain medications. In theory, this could help lower plan costs by:

• Reducing the need for physician visits solely to obtain prescriptions
• Decreasing the volume of drugs processed through the prescription benefit

However, there may be tradeoffs. OTC medications are typically paid for directly by employees and may not be tracked or reimbursed through the health plan, potentially shifting more out-of-pocket costs to members and reducing employer visibility into utilization patterns.

Insurance Premium Reductions and Increased Price Transparency

The proposal emphasizes price transparency, calling for clearer cost reporting from insurers and healthcare providers.

For self-funded employers, transparency is already a core value and a key reason many partner with a third-party administrator like 90 Degree Benefits. Additional transparency requirements could further support:

• More accurate benchmarking
• Better provider comparisons
• Stronger leverage in contract negotiations

Greater access to actionable cost data strengthens employers’ ability to manage healthcare spend without sacrificing quality of care.

Federal Funds Directed to Individuals, Not Insurers

Another component of the proposal would redirect certain federal healthcare funds directly to individuals, potentially through health savings accounts (HSAs) or similar consumer-directed mechanisms.

This aspect primarily affects the individual insurance marketplace, not ERISA-governed group health plans. However, broader shifts in how individuals access and fund coverage could indirectly influence:

• Plan design strategies
• Employer contribution approaches
• Market dynamics between self-funded and fully insured options
• Overall insurance pricing trends

Potential Positive Implications for Employers

If enacted as written, elements of the proposal could present opportunities for self-funded employers:

• Reduced Prescription Drug Spend
  • Pricing reforms may help lower overall pharmacy costs for self-funded plans.
• Greater Cost Transparency
  • Enhanced reporting requirements could make it easier to evaluate provider performance and negotiate more effectively.
• Expanded Plan Design Flexibility
  • Increased emphasis on HSAs and consumer-directed benefits may support broader adoption of high-deductible or value-based plan designs.

What Employers Should Watch Next

At this stage, the proposal remains conceptual and would require Congressional action to move forward. As with any federal healthcare initiative, the final version, if enacted, could look significantly different from the initial outline.

The legislative process will determine:

• Whether the proposal advances
• Which components are modified or removed
• How and when any changes would take effect

Our Commitment to Brokers and Employers

90 Degree Benefits will continue monitoring state and federal healthcare regulatory developments and translating them into clear, actionable guidance. Our goal is to help brokers and employers:

• Stay compliant
• Anticipate regulatory shifts
• Design smarter healthcare plans that balance quality care with meaningful cost control

If you have questions about how potential regulatory changes could impact your plan strategy, our team is here to help.

Ready to speak with an expert about your benefits strategy?

FAQs: Trump’s Healthcare Proposal and Self-Funded Health Plans

Does Trump’s healthcare proposal affect self-funded employer health plans?

The proposal does not directly change self-funded health plan rules today, but several elements, such as prescription drug pricing reforms and expanded price transparency, could indirectly impact plan costs, negotiations, and long-term strategy for employers.

Will this proposal change ERISA requirements for employer plans?

No. The proposal does not currently amend ERISA. However, market-wide pricing and transparency changes could influence how ERISA plans are designed and managed if the proposal advances.

How could the proposal impact prescription drug costs for employers?

If enacted, Most Favored Nation drug pricing could help lower pharmacy spend for self-funded plans. Expanded over-the-counter access may also reduce prescription claims, though it could shift some costs directly to employees.

Does expanded price transparency benefit self-funded employers?

Yes. Greater transparency from providers and insurers could improve cost benchmarking, strengthen negotiations, and give employers better insight into healthcare spending without reducing care quality.

Should employers make plan changes now?

No immediate action is required. The proposal is still conceptual and would require Congressional approval. Employers should monitor developments and consult with their broker or TPA before making any plan design changes.

How is 90 Degree Benefits helping employers navigate potential changes?

90 Degree Benefits monitors federal and state healthcare policy and translates regulatory developments into practical guidance, helping employers and brokers stay compliant and plan strategically.

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For brokers and consultants, the takeaway is simple: change is coming, and preparing your clients now will put them in a stronger position later. Here’s what to watch.

How TrumpRx Could Affect Employer Health Plans

TrumpRx is designed to lower pharmacy costs by:

• Directing patients to purchase medications directly from manufacturers at government-negotiated prices
• Using international benchmarks to cap certain drug costs
• Increasing pressure on manufacturers to offer deeper discounts

While these goals may lower out-of-pocket costs for some consumers, they also challenge the traditional PBM structure employers rely on today. As the landscape evolves, employers may experience:

• Potential shifts in drug access, pricing, or formulary design
• Pressure to align with newly publicized price benchmarks
• Added complexity to their existing pharmacy benefit strategy

This is where brokers play an increasingly important role, helping clients navigate uncertainty and maintain plan stability without sacrificing quality or cost efficiency.

What Brokers Can Do Right Now

A proactive approach will set your clients up for success. Consider:

1. Access current pharmacy benefit strategies
   1. Understand where pricing shifts could impact each client’s plan
2. Stay informed
   1. Regulations are still taking shape. Keeping up with new announcements is essential.
3. Educate your clients
   1. Share updates early and help employers understand how TrumpRx may affect their plan design.
4. Remain flexible
   1. Implementation will unfold over time. Being adaptable protects both you and your clients.
5. Lean on partners who specialize in cost containment
   1. Working with an experienced pharmacy benefits team can help you identify solutions that keep plans competitive.

How 90 Degree Benefits Support You

At 90 Degree Benefits, we help brokers turn uncertainty into opportunity. Our pharmacy cost-containment expertise, including RightTurnRx, gives you the tools to:

• Reduce drug spend through strategic PBM procurement
• Strengthen contracts with data-driven evaluation
• Improve outcomes with clinical oversight and member-focused engagement

We’re here to help you evaluate evolving policy changes, protect your clients’ bottom lines, and deliver a smarter pharmacy benefit strategy no matter how the market shifts.

Conclusion

How will TrumpRx impact employer pharmacy costs?

TrumpRx may lower certain drug prices by introducing government-negotiated, direct-to-consumer pricing. However, it could also create new variability in employer pharmacy

costs. Because TrumpRx operates outside traditional PBM contracts, employers may see changes in formulary alignment, pricing guarantees, and rebate structures. In many cases, costs won’t disappear—they’ll shift. The real impact will depend on how individual plans are structured and how PBMs respond to federal pricing benchmarks.

What should brokers do right now?

Brokers should begin by reviewing each client’s current pharmacy benefit strategy to identify where pricing shifts could create risk or opportunity. Staying updated on TrumpRx guidance is essential, as the program is still evolving. Most importantly, brokers should proactively educate employers about potential changes and partner with pharmacy benefit experts who can help model scenarios, compare PBM options, and maintain cost stability during the transition.

Does TrumpRx replace PBMs?

No. TrumpRx does not replace PBMs. Instead, it introduces an alternative pathway for certain medications using government-negotiated prices. Employers will still rely on PBMs for formulary management, claims processing, specialty drug oversight, clinical programs, and network administration. TrumpRx may influence how PBMs structure contracts or pricing strategies, but it does not eliminate the need for PBM services in employer-sponsored health plans.

Ready to speak with an expert about your benefits strategy?

REFERENCES

“TrumpRx: How the Drug Pricing Program Works.” https://govfacts.org/explainer/trumprx-how-the-drug-pricing-program-works/ “Inside TrumpRx and its unusual launch.” https://cthosp.org/daily-news-clip/inside-trumprx-and-its-unusual-launch/ “Trump Announces ‘TrumpRx,’ a Government-Run Direct-To-Consumer Drug Website.” https://www.notus.org/healthcare/drug-prices-trumprx-pfizer “Creating unique health plan solutions – 90 Degree Benefits.” https://90degreebenefits.com/solutions/

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Selecting the right Third Party Administrator (TPA) is largely about plan design, network access, claims processing speed, and creative cost containment solutions. However, one aspect that often gets overlooked is partnership and the level of customer service your employees experience every time they reach out for help.

At 90 Degree Benefits, we believe exceptional service is the foundation of successful health plan management. When members feel supported, employers see the difference in satisfaction, retention, and overall plan performance.

Service That Goes Beyond Health Plan Administration

Employers and brokers need more than a TPA that simply processes claims. They need a partner who listens, solves problems quickly, and treats members with empathy and respect.

Every call, every question, every claim is an opportunity to show that care and to make a real impact on someone’s experience with their benefits.

“I cannot think of anything I would change. I truly feel this is an amazing insurance company. I have been so happy with them! Get ready — your life is going to get so much easier!”
— 90 Degree Benefits Member

This kind of feedback is the result of intentional investment in people, training, and technology that put members first.

The Ripple Effect of Caring Customer Service

Exceptional customer service benefits more than just the member on the phone. It creates a ripple effect that strengthens every layer of your health plan ecosystem:

• For members: Fast answers, compassionate support, and a team that genuinely cares about resolving issues.
• For employers: Fewer escalations, happier employees, and a TPA that acts as an extension of your HR team.
• For brokers: Confident clients, smoother renewals, and a partner who helps protect your reputation.

“I can promise you — I have never had the customer service I get from 90 Degree anywhere! … They truly care and go above & beyond all of the time.”
— Client Feedback, Oklahoma

When service feels personal, people notice, and that trust translates into long-term client relationships.

Health Plan Advocacy in Action
Behind every great TPA experience is a team that cares deeply about outcomes. Whether it’s helping an employee navigate a complex or high-dollar claim, coordinating care through a nurse advocate, or stepping in when another administrator falls short, compassion is at the core of what we do.

“The care and compassion I was shown were more akin to close friends than a business arrangement. You should be proud of your team; their excellence is rare.”
— CareConnect Member

That kind of service turns a transaction into a relationship and a benefits plan into a true support system.

Why Customer Service Should Guide Your TPA Choice
When evaluating a TPA partner, it’s easy to focus on cost savings or system capabilities. But the most successful employers know that the member experience is what defines a plan’s value.
Ask yourself:

• Will this partner make it easy for my employees to get help?
• Do they treat every member like a person, not a policy number?
• Will they stand by us when challenges arrive?

At 90 Degree Benefits, we’re proud to answer “yes” to each, because we know that exceptional customer service drives exceptional results.

A TPA Partnership Built on People
As one member put it best: “Your excitement truly made my day, thank you! We have a great partnership, and I appreciate your team so much!”

Partnerships like these are why we do what we do. When employers, brokers, and TPAs work together with a shared purpose, everyone wins, especially the people the plan was designed to support.

Your benefits plan deserves more than administration; it deserves a true partner who answers calls with empathy, resolves claims with urgency, and treats every member interaction as an opportunity to serve.

At 90 Degree Benefits, that’s our promise and the reason our clients, brokers, and members keep saying thank you.

The post The Power of Partnership: Exploring TPA Customer Service appeared first on 90 Degree Benefits.

That was the reality for one Northeastern manufacturing company spending more than $1.1 million annually on employee benefits. With premium hikes ranging from 15% to 30% each year, the employer knew the trend had to stop or they’d have to make drastic cuts.

A Smarter Strategy for Sustainable Savings

When the company partnered with 90 Degree Benefits, we collaborated with their broker to implement a comprehensive, data-driven approach that targeted the key drivers of cost without compromising employee care.

Here’s how we did it:

• Rx Cost Relief: Many plan members qualified for manufacturer drug assistance and government programs, cutting unnecessary pharmacy spend.
• Proactive Medical Management: By implementing medical management, we ensured appropriate care and utilization, improving outcomes while controlling costs.
• Smart Plan Redesign: The benefit plan was restructured to guide members toward high-quality, cost-efficient providers and facilities, improving value across the board.

The Results: Five Years of Measurable Impact

The results speak for themselves. Over five years, this strategic shift delivered consistent, sustainable savings and measurable peace of mind.

• 27% reduction in PMPM costs
  • 2020 PMPM (Actual): $504
  • 2025 PMPM (Projected): $368
• Zero employee premium increases in over five years, despite national healthcare cost trends climbing sharply.

The employer not only broke free from the fully insured cycle of unpredictable rate hikes but also achieved greater member satisfaction and long-term stability.

A Better Way Forward

For this manufacturer, partnering with 90 Degree Benefits meant building a smarter, sustainable plan that puts both the business and its people first.

If your organization is ready to break the cycle of rising healthcare costs, we’re ready to help.

Let’s Make the Right Turn together.

The post How 90 Degree Benefits Cut Healthcare Costs by 27% for One Manufacturer Client appeared first on 90 Degree Benefits.

The data is clear: health costs aren’t slowing down. Prescription drug prices have risen three times faster than inflation since the late 1980s, health premiums are projected to rise 12%+, and we continue to see groups shift from fully insured plans in search of flexibility and savings. To stay ahead, brokers and employers will need smarter strategies and innovative partners to navigate what’s next.

As a leading TPA with a national footprint, 90 Degree Benefits provides unique plan design solutions to help brokers deliver long-term sustainability for their clients.

Top Plan Design Trends for 2026

Here are four key trends we see on the horizon for 2026 and how 90 Degree Benefits helps employers and brokers stay in control:

1. Smarter Care Navigation

Traditional broad PPO networks drive up costs by failing to direct members to the highest-value providers. With CareConnect, 90 Degree Benefits creates a virtual narrow network, steering employees to high-quality, lower-cost providers while simplifying the member experience.

Impact: Up to 15% savings

2. Pharmacy Oversight Becomes Essential

Since the late 1980s, drug prices have increased at nearly triple the pace of inflation. Employers can no longer afford to rely on standard PBMs. RightTurnRx provides PBM oversight, contracting support, clinical cost containment, and alternate funding strategies that save employers up to 30%.

Impact: Up to 30% savings

3. Rising Premiums Demand Innovative Access

With premiums expected to climb 12%+, employers are looking for new ways to deliver affordable, accessible care. Access2Day Health near-site clinics offer zero-copay primary and urgent care, reducing ER visits and improving overall health outcomes.

Impact: Up to 10% savings

4. Shift Away from Fully Insured Plans

According to the 2024 KFF Employer Health Benefits Survey, just 36% of covered workers were in fully insured plans, while the majority were in self-funded or level-funded arrangements. The shift reflects a growing demand for flexibility, transparency, and cost control. With stop-loss advantages gained through programs like CareConnect, RightTurnRx, and Access2Day, 90 Degree Benefits clients often see 15%–25% savings on stop-loss costs.

The 90 Degree Advantage

By integrating these strategies, employers and brokers can finally balance cost, quality, and access without compromise. Our approach isn’t just about reducing spend, it’s about building sustainable, smarter benefits plans that support healthier employees and healthier bottom lines.

2026 will bring new challenges, but with the right TPA partner, brokers and employers don’t have to face them alone.

Ready to get ahead of what’s coming? Let’s Make the Right Turn for your plan together.

The post What’s Ahead for 2026: Smarter Plan Design Starts Now appeared first on 90 Degree Benefits.

Employers are under constant pressure to balance healthcare costs, quality, and access. In a market where delayed care leads to higher claims and diminished productivity, the challenge is real, and it’s not going away. Many self-funded employers are turning to near-site clinic solutions like Access2day Health to lower costs and improve outcomes.

By eliminating barriers to care and integrating with strategic plan designs, Access2day is helping employers achieve this long-sought goal.

Why Near-Site Clinics Work

When cost or convenience becomes an obstacle, employees delay treatment. This often results in their condition escalating and an expensive ER visit or high-cost claim. Access2day solves this problem with employer-sponsored, zero-copay clinics that offer primary care, urgent care, and basic labs.

• The result: Members get the care they need quickly and affordably.
• The benefit to employers: Avoidable claims are reduced, productivity improves, and overall plan costs drop.

This approach not only contains costs, but also changes the entire care experience.

Access2day in Action: Real Results from Real Employers

Across industries, Access2day is delivering measurable results:

• Municipal Case Study: Reduced ER visits by 11% in the first year and saved an estimated $2,692,245 in claims costs over 7 years.
• School System Case Study: Reduced substitute teacher hours driven by absenteeism by 18% and saved an estimated $1,811,950 in claims costs in the first two years.
• State Health Plan Case Study: Improved employee satisfaction and saved an estimated $18,452,059 in claims costs in one year.

These outcomes are the natural result of removing financial and logistical barriers to care.

Beyond Cost Savings – A Better Experience for Everyone

While the numbers speak for themselves, the impact of Access2day extends beyond the balance sheet:

• Convenience → Higher engagement in preventive care.
• Faster treatment → Reduced risk of high-cost claims.
• Increased satisfaction → Stronger employee retention and morale.
• Favorable stop-loss terms → Plans with proven cost-containment strategies like Access2day often secure better rates from stop-loss partners.

It’s a full-spectrum win for employers and their teams.

The 90 Degree Benefits Advantage

When Access2day is integrated into a self-funded health plan through 90 Degree Benefits, employers gain far more than a clinic solution. We help layer additional cost containment and member navigation programs for maximum impact:

• CareConnect – Guides members to the highest-value providers, eliminating surprise bills and improving outcomes.
• RightTurnRx – Delivers up to 30% pharmacy savings without compromising care.
• Seamless Implementation & Management – As your third-party administrator, 90 Degree Benefits ensures these programs work together within your strategic plan design to deliver lasting value.

Make the Right Turn Toward Smarter Healthcare

Access2day is more than a near-site clinic solution; it’s a strategic cost containment tool. When combined with the right funding model and an experienced TPA partner like 90 Degree Benefits, it can help employers reduce costs and create a better benefits experience for everyone.

Ready to see the results for yourself? Let’s design a smarter, self-funded strategy that delivers real savings and better care.

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That’s why you need a third-party administrator (TPA) you can count on, especially as M&A activity continues to shake up the self-funded health plan market. If your current partner feels uncertain, it may be time to consider a smarter solution.

A National TPA Built for Long-Term Success

90 Degree Benefits is a national third-party administrator (TPA) focused on helping employers across the country manage their self-funded health plans with confidence. With 24 offices and 525,000+ members served nationwide, we offer the local service brokers value, backed by the financial stability and scale that gives your clients peace of mind.

While others are downsizing or consolidating, we’re growing:

• 285 new client groups added in January 2025 alone
• 14,600+ new covered lives
• $1.6B+ in claims paid in 2024
• 3.9M+ claims processed
• 95%+ satisfaction scores among large employer groups

This is what real partnership and performance look like. Our continued success is a testament to our commitment to service excellence and continual innovation.

What Makes 90 Degree Benefits Different?

We’re not a one-size-fits-all TPA. We work with brokers across the country to create unique self-funded health plans that control costs, improve outcomes, and meet the needs of every group, no matter the size.

Here’s how we do it:

• CareConnect – Member Advocacy & Navigation
  Our Member Advocacy Program offers hands-on, personalized support that helps members navigate care decisions, avoid surprise bills, and access quality providers.

• RightTurnRx – Proven Pharmacy Cost Containment
  Pharmacy spend remains the fastest-growing area of health plan costs. RightTurnRx is a transparent, aggressive pharmacy savings strategy that cuts Rx spend by 30% or more, without compromising member care.

• Specialized Solutions for Complex Groups
  From municipalities and religious organizations to nonprofits and state risk pools, our flexible plan design capabilities help brokers deliver creative solutions to groups with highly specific needs.

• Local Teams, National Strength
  With 24 regional offices, brokers get the day-to-day accessibility and collaboration of a local partner, combined with the leverage, resources, and innovation of a national TPA platform.

Stop Settling for Health Plan Uncertainty.

If you’re tired of instability, you’re not alone. Brokers across the country are making the right turn to a TPA partner who brings stability, innovation, and relationship-first support to every plan.

90 Degree Benefits is built to last and ready to help you and your clients thrive.

The post Why Brokers Are Reconsidering Their Health Plan Partners appeared first on 90 Degree Benefits.

What Is CareConnect?

CareConnect is more than just a cost-saving program—it provides advocacy for members and employers, ensuring access to high-quality, fairly priced healthcare.

How CareConnect Supports Members:

• Guidance & Support: Answering questions, explaining benefits, and researching procedures.
• Cost Transparency: Researching savings opportunities and educating members on their care options.
• Care Coordination: Helping members choose high-quality, low-cost providers and facilities, facilitating scheduling, and assisting with medical records.
• Billing Advocacy: Reviewing, negotiating, and ensuring fair pricing for services.

CareConnect in Action: A Life-Saving Surgery, A Game-Changing Outcome

The Roadblock

When a patient required emergency heart surgery, they were admitted through the ER at a hospital notoriously unwilling to negotiate. The total charges? A staggering $813,330.89. Not only would this have an immediate financial impact on the health plan and the member, but it could also lead to higher stop-loss premiums at renewal.

The CareConnect Strategy

Understanding the urgency and complexity of the situation, our expert Account Executive team escalated the case to CareConnect’s seasoned negotiators. The team worked quickly, engaging the Hospital Medical Director, the patient’s physician, and other key stakeholders to open communication and initiate negotiations.

By leveraging our deep industry expertise and strategic mediation tactics, CareConnect secured an agreement at 150% of Medicare rates—a monumental success given the facility’s typical resistance to rate adjustments.

The Results? Unmatched Savings.

• Total Charges: $813,330.89
• Negotiated Rate: $90,914.97 (150% of Medicare)
• Total Savings: $722,718.30

Why It Matters

This case is a powerful example of CareConnect’s ability to drive meaningful cost savings and protect plan sponsors and their members from excessive healthcare expenses. Even when faced with providers that resist negotiations, our team delivers results.

Facing a Healthcare Challenge? CareConnect Can Help.

Healthcare navigation shouldn’t be a burden—CareConnect makes it simple. Whether it’s identifying cost-effective care options or negotiating seemingly impossible bills, we ensure that plans and members receive the best possible outcomes without unnecessary financial strain.

Let CareConnect advocate for you.

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If you ask people what’s wrong with healthcare today, the answers typically fall into two categories: it’s too complicated, and it’s too expensive. The data backs this up. According to a 2024 employer health benefits survey conducted by Kaiser Health, the average premium for a family health plan has skyrocketed to $25,572 per year.¹ This rising cost puts immense pressure on employers and employees struggling to keep up with healthcare expenses and brokers trying to find the right solutions to combat the rising cost.

So, how do we solve this? If unit cost × volume = total healthcare cost, then lowering costs requires strategic plan design. The key lies in smarter navigation, oversight, and virtual care. Here’s how:

1. Care Navigation: Building a Virtual Narrow Network with CareConnect

2. Pharmacy Benefit Oversight: Controlling Prescription Drug Costs with RightTurnRx

3. Near-Site Clinics: Reducing Costs with Access2Day Health

Stop Loss Savings: An Added Bonus

By incorporating CareConnect, RightTurnRx, and Access2day, health plans unlock a powerful advantage—not just in cost savings but in the recognition they receive from stop-loss partners. These proven strategies significantly reduce unnecessary emergency room visits, hospitalizations, and overall healthcare and pharmacy utilization by emphasizing directed care and strategic Rx management. The result? Lower costs for routine care, preventative services, specialty pharmacy, and chronic conditions.

90 Degree Benefits clients implementing these programs have seen stop-loss cost savings ranging from 15% to 25%, proving that the right approach to care coordination and pharmacy management isn’t just effective—it’s transformative.

The New Reality: Cost Savings Without Compromise

By integrating these three strategies, employers and brokers can finally achieve the Healthcare Holy Grail—balancing cost, quality, and access in a way that was once thought impossible. This isn’t just about lowering costs; it’s about delivering better care, better access, and better financial outcomes for businesses and their employees.

Ready to make a turn for the better? Let’s build a smarter benefits strategy—one that works for everyone.

¹ https://www.kff.org/report-section/ehbs-2024-section-1-cost-of-health-insurance/

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Understanding Stop Loss Insurance

Self-funded plans provide flexibility to create more customized plans, insights into plan performance, and a higher potential for year-over-year savings. But individual catastrophic claims and overall high spending during a policy year can still happen. Stop loss insurance protects self-funded employers from excessive claim costs. It consists of two key components: specific and aggregate coverage.

Specific Stop Loss Coverage

Specific stop loss applies to individual claimants. For example, if an employer selects a $50,000 specific deductible, they are responsible for an individual’s claims up to that amount. Any costs exceeding $50,000 are filed for reimbursement by the TPA to the stop loss carrier. Employers pay a monthly premium for specific stop loss coverage.

Aggregate Stop Loss Coverage

Aggregate stop loss covers the entire employee population. The carrier sets an expected claims amount based on historical claims data and adds a margin (typically 10-50%). If total claims during the policy year exceed this threshold, the TPA files for reimbursement from the stop loss carrier. Employers pay a monthly aggregate premium for aggregate stop loss coverage.

Selecting the Right Stop Loss Contract

Employers must choose a contract that determines how claims are covered over time. Common options include:

• 12/12 – Covers claims incurred and paid within the same 12-month policy period.
• 24/12 – Covers claims incurred in the prior year and paid in the policy year.
• 12/15 – Covers claims incurred in the policy year and paid within three additional months.
• 15/12 – Covers claims incurred three months before the policy year and paid within the policy year.

For example, a 24/12 contract starting on 1/1/2025 covers claims incurred from 1/1/2025 – 12/31/2026 and paid from 1/1/2025 – 12/31/2025.

Key Stop Loss Considerations and Features

Lasers

Stop loss carriers may assign higher deductibles to high-risk individuals. For instance, an employee with expected claims of $100,000 may receive a laser deductible of $100,000 instead of the standard $50,000 assigned to everyone else on the plan.

No New Laser/Rate Cap Feature

This optional protection prevents new lasers from being assigned and limits renewal rate increases (typically capped at 50%) for an additional percentage added to premium costs.

Aggregating Specific

This option increases employer liability in exchange for lower premiums. For example, with a $50,000 specific deductible and a $30,000 aggregating specific, the employer must cover an additional $30,000 before stop loss reimbursement begins, but their annual premium is typically reduced by the same amount.

Why Work with 90 Degree Benefits?

Navigating stop loss coverage is complex, but 90 Degree Benefits simplifies the process with expert guidance and tailored solutions. As a national TPA, 90 Degree Benefits helps employers optimize self-funded plans while ensuring financial protection.

Make the right turn with 90 Degree Benefits. Our team is ready to help you build a self-funded plan with the right stop loss coverage to protect your clients and members.

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