seCUREme
Stop Loss Insurance – for Groups of 6 or more
The seCUREme Comprehensive Stop Loss Plan is designed for Self-Funded or Third Party Administrated Benefit Plans for businesses with 6 employees or more, often referred to as a “groups”. seCUREme has been created to mitigate the medical financial risk of the employer while still being able to offer their employees attractive and flexible Traditional Extended Health Plans or Health Spending Account plans. And a huge bonus to the Employer is that seCUREme Stop Loss has been priced with Group Rates!
A medical Stop Loss Insurance policy protects employers from assuming all the liability for losses that result from an unexpected number of claims – either from an individual employee or the entire employee group. Under the seCUREme Stop Loss Insurance policy, you are not responsible for claims that exceed certain pre-set limits for the policy year, such as defined benefits per person or annual benefit maximums. When claim expenses go above these defined limits, your Stop Loss insurance will then assume the liability based on your contract. The seCUREme Stop Loss plan will mitigate the employer’s financial risk when self-funding a Tradition Extended Health plan by providing insurance protection against unpredictable and catastrophic claims.
Most often these large catastrophic claims are due to unexpected needs for expensive medications for either short term or extended periods of time. seCUREme Stop Loss insurance allows employers to provide extended benefits to cover these situations within a self-funded plan, while eliminating the financial risk to the business. Small and mid-size businesses can now offer self-funded extended health benefit plans that previously only large companies could afford.
seCUREme Stop Loss insurance from Health Risk Services, covers a comprehensive range of health-related services from emergency ambulance rides and hospital stays to paramedicals, hearing, dental and various other health needs. It can include or exclude Emergency Medical Travel Insurance for travel outside of the Province or Country whether it be for Business or Pleasure!
Most importantly, seCUREme Stop Loss insurance will cover the cost of expensive or long-term prescription drugs – often the most devastating financial concern to a family! You can choose either 80% or 100% coverage and all medications including Generic, Brand Biologic or Bio-Similar Drugs are covered. Biologic and Bio-Similar Drugs are on a Pre-Authorized basis only.
seCUREme Stop Loss insurance attaches to your Traditional Extended Health Plan or Health Spending Account by your selection of one of these Deductibles:
$2,500.00, $5,000.00 or $10,000.00
Like the deductible on Auto Insurance where the Insured is responsible for paying the deductible amount prior to the Insurance commencing, the seCUREme Stop Loss deductible amount purchased is first paid through the Traditional Extended Health Plan or Health Spending Account and then the seCUREme Stop Loss benefits become payable. The deductible chosen will determine the Monthly cost of your seCUREme Stop Loss Plan.
If you have had Stop Loss insurance on a plan prior to purchasing seCUREme Stop Loss, we may be able to Grandfather all the current employees from the existing plan to your new seCUREme. If you have not had prior Stop Loss insurance on your Group Benefit Plan, then your group will be underwritten based on past and present claims experience.
Many of the seCUREme Stop Loss Insurance benefits will reimburse at 100% up to the specified plan maximum. Some of the benefits such as the Paramedicals and Dental reimburse at the specified levels as per the Plan Description.
seCUREme Stop Loss Insurance provides sustainable financial security with added benefits, convenience, and lower premium costs. seCUREme Stop Loss– a terrific way to protect yourself, your employees and your business!
Contact Your Broker or Health Risk Services today and see how seCUREme can work for you!!
Overview of the seCUREme Stop Loss
Prescriptions:
With so many choices for Prescribed Medications in today’s marketplace, it is excellent to know that seCUREme Stop Loss will provide coverage for Generic, Brand & Biologic prescribed drugs. Prior Authorization will be required for approval of any Biologic medication. The plan will cover costs of Prescription Drugs up to $100,000.00 per person per policy year.
You can choose between two coverage options:
- Option One will reimburse 80% of Prescription Medications
- Option Two will reimburse 100% of Prescription Medications
Smoking Cessation, anti-obesity, fertility and lifestyle drugs are not covered under seCUREme.
There is a maximum Dispensing Fee of $12.30 that will be covered per script.
When a CONFIDENTIAL Medical Declaration is required there may be Pre-Existing Conditions that will be excluded from Drug Coverage. If that is the case, challenge to the exclusion if the condition has changed can be made on the Renewal Date of the policy.
Professional Services:
The seCUREme Stop Loss Plan will reimburse 100% of the costs associated with covered professional services to a maximum of $50 per visit with a policy year maximum of $350 CAD per practitioner. The professional services seCUREme will cover include registered or certified massage therapists, chiropractors, physiotherapists, psychologists, osteopaths, naturopaths, speech therapists, podiatrists, psychiatrists, social workers, and acupuncturists. All paramedical professionals must be on the approved list of Regulated Health Care Professionals in their Province in which the service is being performed.
Ambulance:
seCUREme Stop Loss will cover charges up to a maximum of $5,000 CAD for licensed ground or air ambulance transportation to the nearest Hospital, or from one Hospital to another or from a Hospital to the Insured Person’s residence. Air ambulance is eligible under this provision only when the emergent situation indicates that a ground ambulance cannot reach the scene easily, quickly or the terrain makes air transportation the most practical and was Medically Necessary.
Accidental Dental:
seCUREme When an accidental blow to the mouth or face results in Injury to an Insured Person, seCUREme Stop Loss will pay up to a maximum of $2,500 CAD per Insured Person per Policy Term for the Emergency dental treatment necessary to restore or replace permanently attached artificial teeth or sound natural teeth lost or damaged in an Accident, and for which dental treatment is initiated within thirty (30) days following an Accident and completed within the Policy Term. Detailed medical documentation from a Physician or Dentist must be provided to support an Insured Person’s claim.
Hospital Benefits:
When, by reason of Injury or Sickness, an Insured Person is confined to a Hospital, seCUREme Stop Loss will pay the Reasonable and Customary Costs for room and board charges (semi-private or private room accommodation up to $150 CAD per day and a maximum of $5,000 per Insured Person per Policy Term) over and above the applicable Provincial Government Health Care Plan, including the costs relating to Physicians, Surgeons, nursing, operating room, prescription drugs, dressings, Diagnostic Services, medical appliances, and any other Medically Necessary cost incurred by the Hospital for Inpatient Hospital Services, Day patient Hospital Services, as well as costs incurred in an intensive care unit.
Private Duty Nursing at Home:
seCUREme Stop Loss will cover the Reasonable and Customary Costs up to a maximum of $3,000 CAD per Insured Person per Policy Term for the medical services of a licensed Nurse Practitioner in the Insured Person’s home when prescribed by a Physician and related directly to a medical condition for which the Insured Person has received or is receiving treatment covered under this Policy. The nurse cannot be an Immediate Family Member or currently residing with the Insured Person.
Prosthetic Devices:
seCUREme Stop Loss will cover Prosthetics when required as a result of a surgical procedure up to a maximum of $500 CAD per Insured Person per Policy Term.
Non-Durable Medical Supplies:
seCUREme Stop Loss Coverage will cover Non-Durable medical supplies such as cast, splints, canes, slings, trusses, and braces for temporary therapeutic relief when prescribed by a Physician, Surgeon, Physician’s Assistant, or Nurse Practitioner up to a maximum of $1,000 CAD per Insured Person per Policy Term.
Assistive Medical Supplies:
seCUREme Stop Loss Coverage will cover the rental (or purchase, at the option of the Insurer) of Hospital-type bed, ventilator, respirator, hearings aids or other approved Durable Medical Equipment for temporary therapeutic use and the temporary rental of a wheelchair when prescribed by a Physician, Surgeon, Physician’s Assistant, or Nurse Practitioner up to a maximum of $2,500 CAD per Insured Person per Policy Term.
Orthopedic Footwear / Orthotics:
seCUREme Stop Loss Coverage will cover Orthopedic footwear or orthotics up to a maximum of $300 CAD per Insured Person per Policy Term.
Emergency Medical Travel Insurance:
If an Insured Person is temporarily outside of their province of residence or out Canada, seCUREme Stop Loss Coverage will reimburse the Reasonable and Customary Costs of Medically Necessary Outpatient treatment provided by or under the care of a Physician or Surgeon that an Insured Person needs by reason of Injury or Sickness in an Emergency situation.
If it is deemed Medically Necessary to evacuate an Insured Person who has a critical medical condition as determined by the Insurer to the nearest Hospital equipped to provide appropriate care and facilities, seCUREme will reimburse the Reasonable and Customary Cost of emergency evacuation and medical care to such Hospital. seCUREme will also reimburse reasonable transportation costs for one other person accompanying the patient when this is deemed necessary, and will pay the cost of a one-way economy airfare back to Canada. If this Benefit is provided by another insurer, this Policy automatically becomes the second payor.
seCUREme Stop Loss Coverage provides 100% coverage up to a maximum $100,000.00 CAD for trip of up to 30 days in duration with an aggregate maximum of 90 days per Insured Person per Policy Term.
Dental Coverage:
Individuals insured under the seCUREme Stop Loss Coverage plan will be happy to hear that they are covered for 80% of Basic Dental procedures and 50% of Major Dental procedures. There is a combined maximum coverage of $1250.00 CAD per Policy Term for Basic and Major services. There is a 9 month waiting period for major coverage to become effective.
That means you can expect to be reimbursed 80% of the costs of examinations, x-rays, cleanings (every 9 months), fillings and extractions, periodontics, and endodontic.
For Major treatments, you can expect to be reimbursed 50% of the cost of dentures, bridges, crowns, inlays/onlays, and implants.
NOTE: Dental Fee Reimbursement – Current Practitioner Pricing that is Reasonable and Customary in the area where the expense is incurred.
Basic Dental Procedures will include:
- Complete Examinations – Every 60 months
- Recall Examinations – Every 9 months
- Specific Examination (including endodontic, periodontics, surgical & emergency
- Cleaning and prophylaxis and fluoride for children under age 19 – Every 9 months
- Periodontal scaling and root planning – 10 units every policy term
- Gum surgery
- Panoramic x-ray – Every 60 months
- Bitewing x-ray – Maximum of 4 every policy year
- Periapical Films
- Fillings (composite and Amalgam)
- Surgical Extractions
- Endodontic – Root Canal Therapy
Major Dental Procedures will include:
- Dentures, Bridges, Crowns, Inlays/Onlays & Implants
Optional Riders available for seCUREme Stop Loss
Vision Care
- Optional seCUREme Vision Care provides coverage of $250.00 per Insured person every 24 months.
- The Vision Care option provides coverage for Eye Examinations, Prescription Eye Wear (glasses & contacts) and Laser Eye Surgery.
Orthodontic Coverage
- Optional Orthodontic Coverage provides coverage at 50% of your costs up to a lifetime maximum of up to a lifetime maximum of $2000.00 Per person insured.
- seCUREme Orthodontic Coverage is limited to dependent children under the age of 19.
- There is a 9 month waiting or eligibility period for Orthodontic Coverage to become effective.
seCUREme provides Stop Loss coverage and financial security with added benefits, convenience and lower premium costs. seCUREme Stop Loss – a great way to protect yourself, your employees and your business!
NOTE:
Further description of ALL seCUREme Stop Loss Benefits will be identified in the Policy Contract.
Click HERE to review a seCUREme Sample Stop Loss Coverage Policy Contract.
Click HERE to review a seCUREme PDF Description of Stop Loss Coverage