Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 169 - Regulation 116-Stop-Loss or Excess Policies of Insurance
Section XIII-16911 - Policy Form Requirements
Universal Citation: LA Admin Code XIII-16911
Current through Register Vol. 50, No. 9, September 20, 2024
A. Stop loss or excess policy forms intended to cover the losses of a group health plan must include the following requirements.
1.
Eligible claims incurred under the group health plan during the initial
contract period will be covered, as long as the "group health plan" submits to
the stop loss or excess insurer proof of payment of the eligible claim within
90 days after the expiration of the policy, or within any longer period that is
provided in the contract or policy.
2. All applications for stop-loss or excess
coverage must include the option to purchase a policy providing coverage on a
run-out contract basis. A run-out contract basis extends the claims paid period
for at least 90 days beyond expiration of the twelve-month contract term, the
period within which claims incurred during the contract term must be submitted
and paid.
3. All applications for
stop-loss or excess insurance coverage that include the option to purchase a
policy providing coverage restricted to claims both incurred and paid during
the contract term must contain a form for acceptance or rejection of the
ninety-day extension for claims to be submitted and paid, i.e., run-out
coverage. To reject such offer, the applicant and the writing producer must
both sign and date the application or a supplemental application form
containing disclosures such as the following.
a. "It is hereby agreed and understood that
the stop-loss [excess] insurance contract selected does not provide
reimbursement to the plan sponsor for any expenses incurred under the "group
health plan" prior to the beginning of the contract period for stop-loss
[excess] insurance or for any expenses paid after expiration of the contract
period. Only eligible expenses that are both incurred under the group health
plan and paid by the group health plan within the twelve-month contract period
for stop-loss [excess] insurance are reimbursable under the contract selected.
"
4. All applications
for stop-loss or excess insurance including options to purchase a policy
providing coverage on a run-in or a paid contract basis must contain a form for
acceptance or rejection. To reject such offer, the applicant and the writing
producer must both sign and date the application or a supplemental application
containing a disclosure such as the following.
a. "It is hereby agreed and understood that
the stop-loss [excess] insurance contract selected does not provide
reimbursement to the plan sponsor for any expenses that are not paid by the
group health plan within the current contract period, unless the policy is
subsequently renewed. Only eligible expenses that are both incurred and paid by
the group health plan within the stated contract period are reimbursable under
the contract selected."
5. If offered, provisions for terminal
liability coverage must extend the period for payment of claims under the group
health plan by at least an additional 90 days from termination of the run-out
coverage period allowed for incurred claims.
AUTHORITY NOTE: Promulgated by the Department of Insurance, Office of the Commissioner, in accordance with R.S. 22:2 and 22:883.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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