31.10.43.03

.03 Rules for Providing the Medical Stop-Loss Insurance Disclosure Form.

A. Before entering into a policy or contract of medical stop-loss insurance with a small employer, a carrier shall provide the small employer a completed medical stop-loss insurance disclosure form.

B. When determining whether an employer satisfies the definition of a small employer, the carrier shall base the determination on the definition that applies on the proposed effective date of the medical stop-loss insurance policy or contract.

C. The medical stop-loss insurance disclosure form shall be printed in at least 12-point type.

D. The portion of the medical stop-loss insurance disclosure form that requires a listing of any limitations in the medical stop-loss insurance policy or contract is required to include any:

(1) Dollar limitations in the medical stop-loss insurance policy or contract, such as annual limitations;

(2) Day or visit limits on the services covered under the medical stop-loss insurance policy or contract;

(3) Limitations or exclusions that apply to benefits covered under the medical stop-loss insurance policy or contract, such as:

(a) Pre-existing condition exclusions;

(b) Exclusions or limitations for particular services, such as an exclusion or limitation for prescription drugs or mental health services;

(c) Exclusions or limitations for particular medical conditions, such as AIDS;

(d) Limitations or exclusions for non-medically necessary services; and

(e) Limitations or exclusions for experimental or investigational services; and

(4) Different attachment points for any particular service, such as organ transplants.