Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 169 - Regulation 116-Stop-Loss or Excess Policies of Insurance › Section XIII-16905 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Group Health Plan
-an employee welfare
				  benefit plan as defined in Section 3(1) of the Employee Retirement Income
				  Security Act of 1974 (29
				  U.S.C. 1002(1))  to the
				  extent that the plan provides medical care as defined in this regulation and
				  including items and services paid for as medical care for employees or their
				  dependents, as defined under the terms of the plan, directly or through
				  insurance, reimbursement, or otherwise, or only to a multiple employer welfare
				  arrangement that is a self-insurer and does not include those multiple employer
				  welfare arrangements that meet the definition in
				  29
				  U.S.C. 1002(40).
Medical Care
-amounts paid for the diagnosis,
				  cure, mitigation, treatment, or prevention of disease, or amounts paid for the
				  purpose of affecting any stricture or function of the body; transportation
				  primarily for and essential to such medical care; and amounts paid for
				  insurance covering such medical care, as defined in
				  R.S.
				  22:1061(l)(b).
Paid Contract Basis
-allows claims incurred
				  under a "group health plan" during the contract period of a stop-loss or excess
				  policy to be paid during the policy's twelve-month contract period.
Run-in Contract Basis
-allows for
				  reimbursement of claims incurred under a group health plan during a stated
				  period prior to the effective date of the twelve-month contract period of a
				  stop-loss or excess policy and paid during the twelve-month contract
				  period.
Run-Out Contract Basis
-allows for
				  reimbursement of claims incurred under a group health plan during the stated
				  twelve-month contract period and paid within a stated period extending at least
				  90 days after expiration of the twelvemonth contract period.
Self-Insurance Plan
-any contract, plan,
				  trust, arrangement, or other agreement which is established or maintained to
				  offer or provide health care services, indemnification, or payment for health
				  care services, or health and accident benefits to employees of two or more
				  employers, but which is not fully insured. Any such contract, plan, trust,
				  arrangement, or agreement shall be deemed fully insured only if said services,
				  indemnification, payment, or benefits are guaranteed under a contract or policy
				  of health insurance issued by an insurer authorized to transact business in
				  this state. The term
self-insurance plan
shall not include any
				  arrangement or trust formed under Subpart J of Part I of Chapter 10 of Title 23
				  of the Louisiana Revised Statutes of 1950 (R.S.
				  23:1191 et seq.), single employer plans,
				  plans exempt from the state insurance laws under the provisions of the Employee
				  Retirement Income Security Act of 1974 (29 U.S.C.
				  1001 et seq.), except as provided in
				  R.S.
				  22:463, the Office of Group Benefits, plans
				  of political subdivisions, health maintenance organizations regulated under the
				  Health Management Organization Act,
				  R.S.
				  22:241 et seq., plans regulated under
				  R.S.
				  33:1342, 1343, 1346, or 1349, and plans
				  otherwise regulated as insured plans under this Title. A plan of a fraternal
				  benefit society or a labor organization shall not be considered a
				  self-insurance plan for the purposes of this Subpart to the extent that such
				  plan provides health and accident benefits to its members and any of their
				  dependents that are supplemental to those of an employer-provided plan.
Self-Insured Multiple Employer Welfare
				  Arrangement
-a multiple employer welfare arrangement as defined in
				  29
				  U.S.C. §
										1002(40).
Self-Insurer
-any entity that makes,
				  provides, or issues a self-insurance plan and is licensed by the LDI.
Stop-Loss
or
Excess
				  Policy/Policies
-insurance covering the losses of an insured above a
				  specific amount or a self-insurer for losses over a stated amount.
Terminal Liability
-group health plan that
				  provides an extra ninety days of protection upon termination of the Runout
				  contract period.
AUTHORITY NOTE:
				  Promulgated by the Department of Insurance, Office of the Commissioner, in
				  accordance with
				  R.S.
				  22:2 and
				  22:883.