Definitions for "Stop-Loss Provision"
Health insurance policy provision specifying that the insurer will pay 100 percent of the insured's eligible medical expenses after the insured has incurred a specified amount of out-of-pocket expenses under the coinsurance feature.
A provision in a risk-based contract that caps the amount of money for which an MCO is liable or establishes the maximum expense a provider can incur before the capitation rate structure changes. In a stop-loss agreement, the purchaser agrees to provide additional payment to the MCO in certain situations of loss. Also the maximum amount a beneficiary will have to pay out-of-pocket for deductible or coinsurance or copayments.
A provision in a risk-based contract that (1) caps the amount of money for which a healthcare organization is responsible when spending for services exceeds budgeted amounts, and (2) that identifies a means (e.g., stop loss insurance) to pay for these services.