Under stop-loss, a specific deductible describes.

Under stop-loss, a specific deductible describes.

• A. The deductible that applies to an entire group's claims for the policy year.
• B. The deductible that applies to an individual's claims before reimbursement by the insurer begins.
• C. The annual maximum out-of-pocket limit.
• D. The premium charged for coverage.

Answer: (B)

In stop-loss, the specific deductible is the amount an individual must pay out-of-pocket for that person’s eligible medical expenses before the insurer starts reimbursing that person’s claims for the policy year. It resets for each covered individual. For example, if the specific deductible is $5,000 and an employee incurs $7,000 in covered expenses, the employee pays the first $5,000. After that, the insurer begins to reimburse the remaining eligible costs for that person (subject to any coinsurance and the policy’s stop-loss limit). This per-person threshold is distinct from aggregate stop-loss, which looks at total claims across the group. It’s also different from the annual out-of-pocket maximum (a cap on what you pay in a year) and from the premium (the cost of the coverage).

In stop-loss, the specific deductible is the amount an individual must pay out-of-pocket for that person’s eligible medical expenses before the insurer starts reimbursing that person’s claims for the policy year. It resets for each covered individual.

For example, if the specific deductible is $5,000 and an employee incurs $7,000 in covered expenses, the employee pays the first $5,000. After that, the insurer begins to reimburse the remaining eligible costs for that person (subject to any coinsurance and the policy’s stop-loss limit). This per-person threshold is distinct from aggregate stop-loss, which looks at total claims across the group. It’s also different from the annual out-of-pocket maximum (a cap on what you pay in a year) and from the premium (the cost of the coverage).