La. Admin. Code tit. 37 § XIII-16911

Current through Register Vol. 50, No. 6, June 20, 2024

Section XIII-16911 - Policy Form Requirements

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.

La. Admin. Code tit. 37, § XIII-16911

Promulgated by the Department of Insurance, Office of the Commissioner, LR 46699 (5/1/2020).

AUTHORITY NOTE: Promulgated by the Department of Insurance, Office of the Commissioner, in accordance with R.S. 22:2 and 22:883.