Although the 2026 renewal process is already upon us, rising healthcare costs and uncertainty have resulted in a complex health insurance landscape that requires continual review for self-funded plans. Stop loss insurance risk is changing due to specialty pharmacy costs, especially for the increased use of GLP-1 drugs, unpredictable large claims, and the rise of new gene therapies.
The International Foundation recently hosted a webcast titled, “2025 Medical Stop-Loss Premium Survey – Key Findings and Top Renewal Strategies”, with speaker Ryan Siemers, CEBS, Principal of Aegis Risk LLC. Siemers presented results from the 19th year of the 2025 Aegis Risk Medical Stop-Loss Premium Survey, cosponsored by the International Society of Certified Employee Benefit Specialists. This year’s survey represents 1,268 plan sponsors covering over 1,200,000 employees with more than $1.2 billion in annual stop-loss premium and ranging in size from 17 employees to over 21,000.
Siemers reported on the survey findings including why this year’s renewal may lead to a challenging process for many plan sponsors.
Specific vs. Aggregate stop loss
Beginning the discussion on stop loss insurance is an explanation of the two types of stop loss coverage: specific and aggregate. Some basic points to explain the differences between the two include:
Specific
- Most common form of stop loss
- Protection against the volatility of individual high-cost claimants
- Reimburses claims beyond a specific deductible per individual member, dependent, etc.
- Contract language is based upon when a claim is incurred and when it is paid, for example claim incurred in a 12-month period and paid within that 12-month period is known as 12/12.
Aggregate
- Protects the plan from higher than anticipated utilization for the entire group
- Reimburses the plan if the overall expense exceeds a threshold, usually 125% of expected claims
- Preferred by smaller groups or groups that are more risk-adverse
- These types of claims are more uncommon
Siemers says, “Individual stop loss premium varies greatly.” Although many would like to know data on the average cost of stop loss coverage, the average is “hard to measure due to the many different levels of deductibles” that employers choose. In the survey, the data is based on a paid contract basis, which covers claims paid during the 12-month policy period regardless of when the claims were incurred.
In the 2025 version of the survey, common stop loss deductibles are priced based on the average monthly premium per covered employee per month. The 2025 data for various deductible levels includes:
- $100,000 deductible is $229.40;
- $500,000 deductible is $50.96;
- $1,000,000 deductible is $17.69.
The single-year increase for stop loss in 2025 is between 8.8% – 10%. The survey includes additional stop-loss data including deductible amounts by employee size, premiums for aggregate stop loss, contract types used, as well as names of the most prevalent third-party administrators (TPAs) used, which is newly captured in this year’s survey.
Prevalence of catastrophic claimants
In a recent International Foundation survey, “Health Care Costs Pulse Survey: 2026 Cost Trend”, 31% of respondents indicated that catastrophic claims are a primary driver for health plan cost increases. The Aegis survey measured anecdotal (did not request actual claims data) catastrophic claimant responses:
- Claims in excess of $1 million are now reported by 49%, up from 23% in 2024.
- Claims in excess of $2 million are now reported by 16%.
Siemers stated, “There are a lot more $1 million claims as they are a much more reachable claim level in the market today.” Aegis is also tracking $3 million claims, with Siemers saying, “$3 million claims are the new $1 million claim.”
Cancer and specialty pharmacy remain the top two catastrophic claim concerns for plan sponsors, Aegis found. The top claimant conditions include:
- Cancer: 92% in 2025, up from 83% in 2024
- Specialty pharmacy: 47% in 2025, down from 50% in 2024
- Heart/Cardiovascular: 29% in 2025, up from 27% in 2024
- Newborn/Infant care: 26% in 2025, up from 24% in 2024
- Cell and gene therapies: 24% in 2025, down from 29% in 2024
- Lengthy inpatient hospital stays: 12% in 2025, down from 23% in 2024
Inpatient, rare disease, and gene therapy claims
Inpatient stays can be costly due to the many diverse reasons for them including complicated surgeries, long-term illnesses, newborn care, and cancer treatment. Although the above data shows that long inpatient stays are less of a concern for plan sponsor respondents in 2025 than they were in 2024, Siemers commented that, “Long inpatient stays are a common contributor to large claims”, especially as they approach the $2 and $3 million range.
Cell and gene therapies are cited in the survey as a top concern, however, while therapies can realistically exceed $3 million in claims, the occurrences to date have remained minimal. Stop loss carrier QBE North America reported that, gene therapy claims remain rare in its portfolio, with “only three such claims reported between 2022 and 2024 across nearly 2 million covered lives.”
The Aegis survey also addresses that the cell and gene therapy “pipeline is full with 60+ new therapies approved for use by 2030”. Based on the pipeline, Siemers addressed policies for cell and gene therapy. Generally, carveout policies used in a self-funded environment have been for conditions such as organ transplants. Plan sponsors are now looking at stand-alone carveout policies for cell and gene therapies as these have the potential to have a large financial impact on their stop loss coverage and overall plan costs. Considerations for plan sponsors interested in a cell or gene therapy carveout include:
- Review the current plan document language for coverage already included in the plan
- Address carveout coverage with your underwriter
- Determine if there’s a requirement for a specific network or pharmacy benefits manager (PBM) to be used for cell or gene therapy treatment
Renewal strategies and takeaways for plan sponsors
Siemers revealed that several of the largest writers of stop loss coverage, including CIGNA, VOYA, and SunLife, have had “rough” claims experience for the fourth quarter of 2024, due to more advanced cancer treatments, premature births, and health systems trying to increase revenue for their surgical and acute care. All of these will result in higher rate increases in 2026. Some of the suggestions for plan sponsors to consider during their renewal process include:
- Benchmark your plan’s individual stop loss coverage against the data in this survey and other surveys.
- When your plan has positive claims history – show it off when you’re taking your plan to the market.
- Understand the claims disclosure process to ensure unreported claimants don’t become uncovered inadvertently.
- If you make a carrier change, confirm your contract terms.
To learn more about the data from the 2025 Aegis Risk Medical Stop-Loss Premium Survey, watch the full International Foundation’s webcast, 2025 Medical Stop-Loss Premium Survey – Key Findings and Top Renewal Strategies”, which includes a link to the survey.
Developed by International Foundation Information Center staff. This does not constitute legal advice. Please consult your plan professionals for legal advice.
