Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 169 - Regulation 116-Stop-Loss or Excess Policies of Insurance › Section XIII-16911 - Policy Form Requirements

Current through Register Vol. 50, No. 6, June 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.