Consultant: single multimillion-dollar claimant could reshape Lynchburg schools' renewal negotiations

The committee heard that one pending claim could substantially increase next year's premiums and that certain stop-loss contract provisions currently insulating the district may not be available in future renewals. The consultant said the district has a specific stop-loss level of $400,000 and a 50% rate cap in place now, plus a no-new-laser clause that prevents the insurer from isolating the large claimant; he warned Anthem has indicated it may remove those protections for 2027 and beyond.

"This particular claim... is trending to total up somewhere in the neighborhood of four to five million dollars on this one individual," the Mark 3 consultant said, noting the district has already hit its stop-loss for the current year and is scheduled to receive a stop-loss reimbursement next month. He described how insurers sometimes "laser" high-cost individuals — assigning a higher specific attachment point — and that the district's current no-new-laser clause prevents that action for the present contract.

The consultant recommended putting the stop-loss piece of the policy out to bid in 2028 and said the district will evaluate options such as carving out stop-loss, seeking alternative carriers for that layer, or negotiating to retain favorable provisions. Committee members pressed on whether carving out or transferring risk would reduce employee impact; the consultant said many options shift costs in different ways and no single choice eliminates the projected funding gap.