Stop-loss health insurance for small employers of not more than fifty employees - requirements - definitions - rules

(a) Has an annual attachment point for claims incurred per individual that is lower than twenty thousand dollars;

(b) Has an annual aggregate attachment point lower than the greater of:

(I) One hundred twenty percent of expected claims; or

(II) Twenty thousand dollars;

(c) Provides direct coverage of health-care expenses of an individual;

(e) Excludes any employee or eligible dependent from the stop-loss health insurance coverage.

(3) The commissioner may, by rule, change the dollar amounts in subsection

(2) of this section based upon changes in the medical components of the Denver-Aurora-Lakewood consumer price index or its applicable predecessor or successor index. Any change in these dollar amounts must be made at least six months prior to the effective date of the change.

(4) An insurer that issues one or more stop-loss health insurance policies to any person, firm, corporation, partnership, or association actively engaged in business that employed an average of at least one but not more than fifty eligible employees on business days during the immediately preceding calendar year shall file with the commissioner annually an actuarial certification certifying that the insurer is in compliance with this section. The certification must be in a form and manner and contain information as required by the commissioner.

(5) For each stop-loss health insurance policy delivered, issued for delivery, or entered into, the insurer shall prepare a separate exhibit to be given to the insured with the policy containing at least the following information:

(a) The complete costs for the stop-loss health insurance policy;

(b) The date on which the stop-loss health insurance policy takes effect and terminates, including renewability provisions;

(c) The aggregate attachment point and the specific attachment point for the stop-loss health insurance policy;

(d) Any limitations on coverage;

(e) An explanation of monthly accommodation and disclosure about any monthly accommodation features included in the stop-loss health insurance policy; and

(f) A description of terminal liability funding, including:

(I) Costs of processing claims before and after the termination of the policy; and

(II) Maximum claims liability to the employer.

(6) As used in this section:

(a) Actuarial certification means a written statement by a member of the American academy of actuaries, or by another individual acceptable to the commissioner, that an insurer is in compliance with this section, based upon the individual's examination and including a review of the appropriate records and the actuarial assumptions and methods used by the insurer in establishing attachment points and other applicable determinations in conjunction with the provision of stop-loss health insurance coverage.

(b) Attachment point means the claims amount incurred by an insured group beyond which the insurer incurs a liability for payment.

(c) Expected claims means the amount of claims that, in the absence of a stop-loss health insurance policy or other insurance, are projected to be incurred by an insured group through its health plan.