Plan Mirroring

A self-funded employer operates two separate documents:

1. The health plan document (what employees are covered for)
2. The stop loss policy (what the carrier reimburses the employer for)

If those two documents are not aligned, problems arise.

Example:

• Health plan covers a certain specialty drug.
• Stop loss policy excludes or limits it.
• Employer pays the claim.
• Carrier denies reimbursement.

Plan mirroring reduces that mismatch risk.

A plan mirroring endorsement modifies the stop loss contract so that:

• Covered expenses are defined by the employer’s plan document.
• Plan definitions (eligible expenses, limitations, exclusions) are recognized by the stop loss carrier.
• The carrier “mirrors” the health plan design.

It creates structural consistency between the two contracts.

Plan mirroring may apply to:

• Covered medical services
• Pharmacy benefits
• Experimental treatment definitions
• Transplant coverage
• Mental health parity
• Eligibility definitions
• Coordination of benefits
• Internal plan limitations

The goal is to prevent technical denials caused by wording differences.

Plan mirroring does not:

• Override specific stop loss exclusions (e.g., illegal acts, war, etc.)
• Eliminate deductibles
• Remove lasers
• Change contract type (12/12, 12/15, etc.)
• Automatically cover benefits added mid-year without carrier approval

It aligns definitions — it does not remove underwriting controls.

Carriers typically require:

• A copy of the plan document
• Disclosure of unusual benefits
• Approval of non-standard coverage

Some carriers limit mirroring for:

• Experimental treatments
• Gene therapies
• High-cost specialty drugs
• Non-traditional benefit enhancements

Because mirroring increases carrier exposure, underwriting scrutiny may increase.