Ch. Ins 8 NoteNote: Sections Ins 8.20 to 8.32 were created as emergency rules effective October, 1, 1991. Sections Ins 8.40 to 8.56 were created as emergency rules effective February 12, 1992.

Ins 8.11Ins 8.11 County and school district self-insured employee health care benefits: excess or stop-loss insurance requirements.

Ins 8.11(1)(1) Purpose. This section interprets ss. 59.52 (11) (c) and 120.13 (2) (c), Stats., for the purpose of prescribing detailed requirements for excess or stop-loss insurance for self-insured employee health care benefit plans provided by counties or school districts.

Ins 8.11(2)(2) Scope. This section applies to any county or school district that alone or together with one or more counties or one or more school districts provides employee health care benefits on a self-insured basis to less than 1,000 covered employees.

Ins 8.11(3)(a)(a) “Aggregate claims” means total actual claim amounts incurred under the employee health care benefit plan during a benefit period.

Ins 8.11(3)(b)(b) “Aggregate deductible” means the aggregate amount of liability specified in the excess or stop-loss insurance contract at or below which the county or school district remains liable for payments for eligible claims.

Ins 8.11(3)(c)(c) “Benefit period” means a twelve-month accounting or reporting period of the employee health care benefit plan.

Ins 8.11(3)(d)(d) “Coinsurance” means a fixed percentage of each claim established in the employee health care benefit plan which the county or school district is obligated to pay for each person covered in the plan.

Ins 8.11(3)(e)(e) “Covered employees” means employees participating in an employee health care benefit plan.

Ins 8.11(3)(f)(f) “Employees eligible to participate” means employees who are eligible to be covered employees under the terms of the employee health care benefit plan.

Ins 8.11(3)(g)(g) “Employee health care benefit plan” means a self-insured plan established by one county or school district or jointly by 2 or more counties or 2 or more school districts to provide health care benefits to employees eligible to participate in the plan.

Ins 8.11(3)(h)(h) “Expected claims” means the most accurate actuarial estimate of aggregate claims during a benefit period.

Ins 8.11(3)(i)(i) “Incurred” means to have provided or furnished a service or item to an employee or dependent covered under an employee health care benefit plan for which a charge for a covered expense is made.

Ins 8.11(3)(j)(j) “Maximums” means the largest total amount of claims per person established by the employee health care benefit plan which the county or school district is obligated to pay.

Ins 8.11(3)(k)(k) “Paid basis” means the application of a claim payment to the aggregate deductible for the benefit period in which the payment is actually made, regardless of when the claim is incurred.

Ins 8.11(3)(L)(L) “Quota share reinsurance” means insurance purchased for the employee health care benefit plan which pays the plan a predetermined fixed percentage of each claim.

Ins 8.11(4)(a)(a) Excess or stop-loss insurance required by s. 120.13 (2) (c), Stats., shall provide coverage for all claims incurred during the term of the policy or contract at a level at which an actuary has certified that the probability that aggregate claims will exceed 125% of expected claims is less than 5%.

Ins 8.11(4)(b)(b) Each employee health care benefit plan shall be covered by one excess or stop-loss insurance policy that satisfies par. (a), regardless of the number of counties or school districts participating in the plan.

Ins 8.11(4)(c)(c) Notwithstanding par. (a), a county or school district that self-insures employee health benefits under a plan in which an actuary has certified that the probability that aggregate claims will exceed 125% of expected claims is less than one-half percent need not purchase excess or stop-loss insurance.

Ins 8.11(5)(a)(a) Excess or stop-loss insurance required by s. 120.13 (2) (c), Stats., may provide coverage on a paid basis.

Ins 8.11(5)(b)(b) Upon termination for any reason of an excess or stop-loss insurance policy that provides coverage on a paid basis, the policy shall apply all claims incurred but not paid prior to the termination of the policy to the aggregate deductible of the benefit period in which the service or item was provided or furnished to an employee or dependent under the self-insured employee health care benefit plan.

Ins 8.11(6)(a)(a) Every county or school district with a plan that is subject to s. 120.13 (2) (c), Stats., shall file with the commissioner of insurance within 30 days after the effective date of the self-insured employee health care benefit plan, every 3 years thereafter and whenever a material change occurs to the plan, an actuarial certification that includes information on: