§883. Stop-loss insurance coverage
A.Stop-loss coverage shall be defined as insurance covering the loss of an insured
above a specific amount or a self-insurer for losses over a stated amount.
B.Any insurer authorized to issue property and casualty or health and accident
policies of insurance in this state shall report, with its annual statement, any premiums
written in this state for stop-loss or excess insurance coverage to the Department of
Insurance in the manner prescribed by the commissioner.
C.A stop-loss or excess insurance policy form intended for issue to cover losses of
a group health plan, as defined in R.S. 22:1061(1), shall be submitted to the Department of
Insurance for prior approval pursuant to the policy form filing requirements established by
R.S. 22:861 and shall sat
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§883. Stop-loss insurance coverage
A. Stop-loss coverage shall be defined as insurance covering the loss of an insured
above a specific amount or a self-insurer for losses over a stated amount.
B. Any insurer authorized to issue property and casualty or health and accident
policies of insurance in this state shall report, with its annual statement, any premiums
written in this state for stop-loss or excess insurance coverage to the Department of
Insurance in the manner prescribed by the commissioner.
C. A stop-loss or excess insurance policy form intended for issue to cover losses of
a group health plan, as defined in R.S. 22:1061(1), shall be submitted to the Department of
Insurance for prior approval pursuant to the policy form filing requirements established by
R.S. 22:861 and shall satisfy the following conditions:
(1) The stop-loss or excess insurance policy shall be issued to and insure the group
health plan or the plan itself and not the employees, members, or participants.
(2) Payments by the insurer shall be made to the sponsor of the group health plan or
the plan itself and not the employees, members, participants, or providers.
(3) The specific stop-loss or excess limit or attachment point per individual claimant
shall be at least ten thousand dollars. The aggregate stop-loss or excess limit or attachment
point for groups of fifty or fewer shall be, at a minimum, one hundred twenty percent of the
group health plan's total expected claims per policy period. The aggregate stop-loss or
excess limit or attachment point for groups of fifty-one or more shall be, at a minimum, one
hundred ten percent of the group health plan's total expected claims per policy period.
(4) The stop-loss or excess insurance policy shall contain a provision stating that the
bankruptcy or insolvency of the insured shall not relieve the stop-loss carrier from its
obligation under R.S. 22:1269(A).
(5)(a) The stop-loss or excess insurance policy shall contain a provision that eligible
claims incurred under the group health plan during the initial contract period shall be
covered, provided that proof of payment by the plan is furnished to the insurer within ninety
days after the expiration of the policy or any later period that is provided in the contract or
insurance policy.
(b) All applications for stop-loss or excess insurance must include the option to
purchase coverage extending, for at least ninety days beyond the expiration of the contract
term, the period within which claims incurred during the contract term must be submitted
and paid.
(c) All applications for stop-loss or excess insurance 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 offer mandated in
Subparagraph (b) of this Paragraph and must include disclosures as prescribed by the
commissioner.
(d) All applications for stop-loss or excess insurance including options to purchase
a policy providing coverage for claims incurred prior to the contract term, or providing
coverage for claims incurred prior to the contract term but paid during the contract term,
must contain a form for acceptance or rejection of the offer mandated in Subparagraph (b)
of this Paragraph and must include disclosures as prescribed by the commissioner.
(6) The stop-loss or excess insurance policy shall provide coverage with rates not
subject to adjustment by the stop-loss insurer during the policy period, unless any of the
following occur:
(a) There is a change in the benefits provided under the group health plan.
(b) Enrollment under the group health plan changes by at least ten percent.
(7) The stop-loss or excess insurance policy form filed with the Department of
Insurance for approval shall contain a separate document certifying that each of the
requirements specified in Paragraphs (1) through (6) of this Subsection have been met.
D. Stop-loss or excess insurance shall not be equivalent to reinsurance, as
reinsurance only relates to transactions between insurers. An entity purporting to cover a
self-insured group health plan shall be treated as a stop-loss or excess insurer and shall be
subject to the insurance laws and regulations of the state relating to such insurers and to
penalties for violations of such laws and regulations. In no instance shall stop-loss or excess
loss insurance be defined as a contract or policy of health insurance under R.S. 22:452(1)(a).
E. Insurance companies writing stop-loss or excess insurance coverage shall exercise
due diligence in ascertaining the legitimacy or authority of the underlying group health plan
before issuing coverage. This shall include but not be limited to ensuring that the underlying
plan is not a self-insured multiple employer welfare arrangement, as defined in 29 U.S.C.
§1002(40) unless the underlying plan is a self-insurance plan as defined in R.S. 22:452(1)
and is authorized to do business in this state as a self-insurer.
F. Provider stop-loss or excess insurance policies that protect health care providers
from a portion of the financial risk assumed in managed care contracts with health and
accident insurers, health maintenance organizations, and self-insured group plans shall be
submitted to the Department of Insurance for approval and shall satisfy the following
conditions:
(1) The stop-loss or excess insurance policy shall be issued to and insure the
contracted provider or network of health care providers.
(2) Payments by the insurer shall be made to the contracted provider or network of
health care providers.
(3) The individual stop-loss amount, that is, retention or attachment point per
claimant, shall be at least five thousand dollars. The aggregate stop-loss or excess amount
shall be, at a minimum, fifty thousand dollars per calendar year.
(4) The stop-loss or excess insurance policy shall contain a provision that the proof
of loss shall be furnished to the insurer within ninety days after the date that loss is incurred
or any later period that is provided in the contract or insurance policy.
(5) Filings of a stop-loss or excess insurance policy filed with the Department of
Insurance for approval shall contain a separate document certifying that each of the
requirements specified in Paragraphs (1) through (4) of this Subsection have been met.
G. A stop-loss or excess insurance policy form covering any other kind of loss,
damage, or liability may only be written by a property and casualty insurer and shall satisfy
the following conditions:
(1) The stop-loss or excess insurance policy shall be issued to and insure an
individual or business against legal liabilities other than those associated with provision of
health benefits to employees or members of a health benefit plan or managed care health
plan.
(2) Payments by the insurer shall be made to the insured upon provision of proof of
loss.
H.(1) Health stop-loss insurance issued in connection with an employee benefit plan
of a small employer as defined in R.S. 22:1061 shall be issued on or after January 1, 2026,
only if the insurance policy satisfies all of the following:
(a) Is not subject to renewal rate increases exceeding the percentage change in the
medical care index of the consumer price index over the duration of the previous plan year
plus fifty percent, unless an increase greater than fifty percent is actuarially justified.
(b) Has a contract term with guaranteed rates for at least twelve months, without
adjustment, unless there is a change in the benefits provided under the small employer's
health plan during the contract period or the number of employees covered under the plan
increases or decreases by more than fifteen percent.
(c) Includes either a specific attachment point or an aggregate attachment point in a
contract, or both if the parties contract for both.
(d) Aligns stop-loss plan benefit limitations and exclusions with a small employer's
health plan benefit limitations and exclusions, including any annual or lifetime limits in the
employer's health plan except to the extent that the plan benefit or limitation is otherwise
covered by the employer through other insurance.
(e) Pays stop-loss claims incurred during the contract period and paid within twenty-four months after the expiration date of the contract.
(f) Includes provisions to cover eligible plan claims regardless of the termination of
the plan prior to the end of the contract period, subject to the stop-loss contract's minimum
attachment points.
(2) No health stop-loss insurance issued in connection with an employee benefit plan
of an employer with less than five employees shall be issued on or after January 1, 2026, if
the insurance policy contains a provision permitting or authorizing the adjustment of specific
deductibles or attachment points of a plan member or of specific diseases or conditions.
(3) The provisions of this Subsection shall not apply to any policy in effect prior to
January 1, 2026.
I.(1) Any health stop-loss policy issued after January 1, 2026, shall include a separate
disclosure form explaining the limitations of coverage, potential employer risk, and impact
of claims on renewals. The employer shall sign the disclosure form prior to purchasing the
policy.
(2) The commissioner of insurance shall develop a standardized disclosure form no
later than January 1, 2026.