AGGREGATE COVERAGE
Aggregate excess loss
coverage is provided to limit the employer’s overall annual liability
for a self funded plan. This coverage addresses the accumulation of
expenses on all individuals (as opposed to high expenses for
particular individuals) covered under the plan. When eligible expenses
paid during a contract period exceed the annual aggregate deductible,
the group is reimbursed as specified in the contract, typically after
the close of the contract period.
In addition to
medical benefits, most health benefits can be included in the
Aggregate coverage with proper underwriting such as Prescription Drug,
Dental, Vision and Short-Term Disability. Except for Prescription Drug
Coverage, these ancillary charges cannot be included for coverage if
they are a first time benefit offering to plan participants. See the
“General Claim Handling Information” section of the SLG Benefit’s
Claims Guide for more detailed information regarding eligibility of
non-standard expenses under the Aggregate.
The premium charged
for this coverage is expressed as a rate per covered unit per month or
as an amount due annually in advance. New monthly deductible factors,
a new Minimum Aggregate Attachment Point and new rates are established
at each contract renewal.
The Annual Aggregate
Attachment Point is the greater of 1) the sum of Monthly Aggregate
Factor amounts for each month of the Policy Period, determined by
multiplying the total number of Covered Units by the Monthly Aggregate
Factor amounts or 2) the Minimum Annual Aggregate Attachment Point.
The Minimum Annual
Aggregate Attachment Point is the lowest amount of total Payments you
must make under your Plan before you are eligible for reimbursement
under the Aggregate Excess Loss coverage. The Minimum Annual Aggregate
Attachment Point is established based on the first months enrollment
multiplied by the Monthly Aggregate Factor multiplied by the total
number of months and is shown in the Schedule.
The maximum per
Covered Person which may be applied annually to the Annual Aggregate
Attachment Point (i.e. Individual Claim Limit) is also shown in the
Schedule.
CONTRACT OPTIONS
| I. |
Incurred and Paid (12/12)
Eligible Claims will be covered that are in
excess of the group’s Aggregate Attachment Point and are:
- Incurred during the contract Period,
and
- Paid during the Contract Period
|
| II. |
Incurred and Paid with a three month
run-in provision (15/12)
Eligible Claims will be covered that are in excess of the group’s
Aggregate Attachment Point and are:
- Incurred during the Contract Period, or
within three months prior to the beginning of the Contract
Period, and
- Paid during the Contract Period
|
| III. |
Incurred and Paid with a six month
run-in provision (18/12)
Eligible Claims will be covered that are in excess of the group’s
Aggregate Attachment Point and are:
- Incurred during the Contract Period, or
within six months prior to the beginning of the Contract Period,
and
- Paid during the Contract Period
|
| IV. |
Incurred and Paid with a twelve month
run-in provision (24/12)
Eligible Claims will be covered that are in excess of the group’s
Aggregate Attachment Point and are:
- Incurred during the Contract Period, or
within twelve months prior to the beginning of the Contract
Period, and
- Paid during the Contract Period
|
| V. |
Paid
Eligible Claims will be covered that are in
excess of the group’s Aggregate Attachment Point and are:
- Incurred during the Contract Period, or
within 12 months prior to the group’s original effective date
with SLG Benefits.
- Paid during the Contract Period
|
| VI. |
Incurred in the Contract Period and
Paid in the Contract Period plus three months (12/15)
Eligible Claims will be covered that are in
excess of the group’s Aggregate Attachment Point and are:
- Incurred during the Contract Period,
and
- Paid during the Contract Period or
within three months thereafter
|
| VII. |
Incurred in the Contract Period and
Paid in the Contract Period plus six months (12/18)
Eligible Claims will be covered that are in
excess of the group’s Aggregate Attachment Point and are:
- Incurred during the Contract Period,
and
- Paid during the Contract Period or
within six months thereafter
|
| VIII. |
Incurred in the Contract Period and
Paid in the Contract Period plus three months (12/24)
Eligible Claims will be covered that are in
excess of the group’s Aggregate Attachment Point and are:
- Incurred during the Contract Period,
and
- Paid during the Contract Period or
within twelve months thereafter
|
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