Current through February 27, 2024
1. A policy for
stop-loss insurance must:
(a) Not provide
direct coverage of the health care expenses of an individual;
(b) Have an annual specific attachment point
for claims incurred per individual that is not less than $20,000; and
(c) Have an annual aggregate attachment point
for:
(1) Small employer groups that is at
least the greater of:
(I) One hundred and
twenty percent of expected claims; or
(II) Twenty thousand dollars; or
(2) All other groups that is at
least 110 percent of expected claims.
2. For the purposes of this section, an
insurer shall determine on a consistent basis at least annually the number of
natural persons, including, without limitation, employees of the small employer
and dependents of the employees of the small employer, in a group health
plan.
3. If a policy for stop-loss
insurance for a group health plan does not meet the criteria set forth in
subsection 1, the policy will be deemed to be a health benefit plan for the
purposes of this chapter and chapter 689B of NRS.
4. A policy for stop-loss insurance for a
group health plan that is delivered to, issued for delivery to or entered into
with a small employer must include, without limitation, the following:
(a) A provision in the policy for stop-loss
insurance that guarantees the rates of the policy for stop-loss insurance for
at least 12 months, without adjustment, unless there is a change in:
(1) The benefits provided under the group
health plan provided by the small employer that occurs during the term of the
policy for stop-loss insurance;
(2)
The ownership and control of the small employer; or
(3) The number of persons who are covered by
the group health plan changes by more than 15 percent as a result of the small
employer acquiring a separate company or business or the small employer
divesting part of its business to another company;
(b) Both a specific attachment point and an
aggregate attachment point;
(c)
Limitations on benefits and exclusions to coverage that align with the
limitations on benefits and exclusions to coverage of the group health plan
which is provided by the small employer, including, without limitation, any
annual or lifetime limits provided in the group health plan provided by the
small employer; and
(d) A
requirement that the policy for stop-loss insurance must reimburse the small
employer for any claim eligible for reimbursement under the policy for
stop-loss insurance and such a claim is:
(1)
Paid by the insurer within 6 months after the date the policy for stop-loss
insurance contractually ends; or
(2) Not reimbursed as of the termination
date, if any, of the policy for stop-loss insurance.
5. A policy for stop-loss
insurance for a group health plan that is delivered to, issued for delivery to
or entered into with a small employer must not include any provision which
allows:
(a) Lasering; or
(b) Claims to be paid directly to an
individual employee, member or participant.
6. An insurer that issues a policy for
stop-loss insurance shall provide to a small employer applying for a policy for
stop-loss insurance a disclosure on a form prescribed by the Commissioner,
which may be obtained from the Internet website of the Division and may include
the name, identifying logo and address of the insurer.
7. On or before April 1 of each year, an
insurer that issues a policy for stop-loss insurance shall submit to the
Commissioner in a format prescribed by the Commissioner:
(a) If applicable, the experience the small
employer had in Nevada with the policy for stoploss insurance for the previous
calendar year, including, without limitation:
(1) The size of the small employer,
including, without limitation, the number of:
(I) Natural persons, including, without
limitation, employees of the small employer and dependents of the employees of
the small employer, in a group health plan covered by the policy for stop-loss
insurance; and
(II) Employees
eligible for coverage under the group health plan provided by the small
employer as of the beginning of the policy for stop-loss insurance;
(2) The number of member months
for:
(I) All natural persons, including,
without limitation, employees of the small employer and dependents of the
employees of the small employer, in a group health plan covered by the policy
for stop-loss insurance; and
(II)
Employees eligible for coverage under the group health plan provided by the
small employer and enrolled in the group health plan covered by the policy for
stop-loss insurance for the previous calendar year;
(3) The specific attachment point;
(4) Expected claims in the absence of a
policy for stop-loss insurance;
(5)
Expected claims under the specific attachment point;
(6) The aggregate attachment point;
(7) The earned premium; and
(8) Any claims paid by the policy for
stop-loss insurance, including, without limitation:
(I) Specific losses resulting from claims
incurred by a natural person, including, without limitation, an employee of the
small employer or a dependent of an employee of the small employer, who is a
member of the insured group; and
(II) Aggregate losses incurred by the insured
group; and
(b)
A certificate of compliance with the requirements of this
section.
8. Guaranteed
issue and guaranteed renewability do not apply to a policy for stop-loss
insurance governed by this section.
9. As used in this section:
(a) "Actively-at-work exclusion" means the
exclusion of a natural person, including, without limitation, an employee of
the small employer, who is a member of the group health plan offered by a small
employer from coverage because the natural person is:
(1) An employee of the small employer;
and
(2) Is not actively at work as
a result of the use of earned leave.
(b) "Attachment point" means the amount of
claims incurred by an insured group beyond which an insurer incurs a liability
for payment.
(c) "Expected claims"
means the amount of claims that, in the absence of a policy for stoploss
insurance or other insurance, are projected to be incurred by an insured group
through its group health plan and that would be eligible for reimbursement
under a policy for stop-loss insurance.
(d) "Group health plan" has the meaning
ascribed to it in NRS 689B.390.
(e)
"Health care expenses" means the expenses of a group health plan associated
with the delivery of services for health care.
(f) "Lasering" means:
(1) Assigning a different attachment point
for a natural person, including, without limitation, an employee of the small
employer or a dependent of an employee of the small employer, based on his or
her expected health care costs or diagnosis;
(2) Assigning a deductible to a natural
person, including, without limitation, an employee of the small employer or a
dependent of an employee of the small employer, that must be met before
coverage under a policy for stop-loss insurance applies;
(3) Denying coverage under a policy for
stop-loss insurance to a natural person, including, without limitation, an
employee of the small employer or a dependent of an employee of the small
employer, who is otherwise covered by the group health plan provided by the
small employer; or
(4) Applying an
actively-at-work exclusion to a policy for stop-loss insurance.
(g) "Policy for stop-loss
insurance" means insurance purchased by an employer to limit exposure to claim
expenses under a group health plan provided by the employer.
(h) "Small employer" has the meaning ascribed
to it in NRS 689C.095.
(i)
"Specific attachment point" means the amount of claims incurred per natural
person, including, without limitation, an employee of the small employer or a
dependent of an employee of the small employer, who is a member of the insured
group above which an insurer incurs a liability for payment.
(j) "Termination date" means a date upon
which a policy for stop-loss insurance is terminated before the end date
contractually provided in the policy for stop-loss insurance.
Added to NAC by Comm'r of
Insurance by R113-00, eff. 3-30-2001; A
by
R186-22A,
eff. 12/14/2022
NRS 679B.130
