TITLE XXXVII
INSURANCE

Chapter 415
ACCIDENT AND HEALTH INSURANCE

Section 415:1

    415:1 Filing Policies and Rates. – No policy of insurance against loss or expense from the sickness, or from the bodily injury or death by accident of the insured shall be issued or delivered to any person in this state nor shall any application, rider or endorsement be used in connection therewith until a copy of the form thereof and of the classification of risks and the premium rates, or, in the case of cooperatives or assessment companies the estimated cost pertaining thereto have been filed with the insurance commissioner nor until the expiration of 30 days thereafter unless the commissioner shall sooner give his written approval thereof.

Source. 1913, 226:1. PL 281:1. RL 331:1. 1947, 162:1, eff. May 28, 1947.

Section 415:2

    415:2 Disapproval of Forms. –
I. The commissioner may, within 30 days after the filing of any such form, disapprove such form if:
(a) The benefits provided therein are unreasonable in relation to the premium charged;
(b) It contains a provision or provisions which are unjust, unfair, inequitable, misleading, deceptive or encourage misrepresentation of such policy; or
(c) It does not comply with the requirements of law.
II. The 30-day period under paragraph I may be extended by the commissioner if the insurer has not provided all necessary information required to make a determination under paragraph I.
III. If the commissioner shall notify the insurer which has filed any such form that it does not comply with the provisions of this chapter, it shall be unlawful thereafter for such insurer to issue such form or use it in connection with any policy. In such notice the commissioner shall specify the reasons for his disapproval and state that a hearing will be granted within 20 days after request in writing by the insurer.

Source. 1913, 226:1. PL 281:2. RL 331:2. 1947, 162:2. 2008, 212:7, eff. June 16, 2008.

Section 415:3

    415:3 Subsequent Disapproval. – The commissioner may at any time, after a hearing of which not less than 20 days' written notice shall have been given to the insurer, withdraw his approval of any such form on any of the grounds stated in this chapter. It shall be unlawful for the insurer to issue such form or use it in connection with any policy after the effective date of such withdrawal of approval. The notice of any hearing called under this section shall specify the matters to be considered at such hearing and any decision affirming disapproval or directing withdrawal of approval under this chapter shall be in writing and shall specify the reasons therefor.

Source. 1947, 162:3, eff. May 28, 1947.

Section 415:4

    415:4 Review of Disapproval. – The action of the commissioner in this regard shall be subject to review by the superior court.

Source. 1913, 226:1. PL 281:3. RL 331:3.

Section 415:5

    415:5 Form of Policy. –
I. No policy of accident and sickness insurance shall be delivered or issued for delivery to any person in this state unless:
(1) The entire money and other considerations therefor are expressed therein; and
(2) The time at which the insurance takes effect and terminates is expressed therein; and
(3)(a) It purports to insure only one person, except that a policy may, at the election of the carrier, insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children, or any other person dependent on the policyholder. In the event a carrier elects to provide coverage for dependent children, the term "dependent child" shall include a subscriber's child by blood or by law, who is under age 26.
(b) Nothing in this subparagraph shall be construed to require:
(1) Coverage for services provided to a dependent before the effective date of this section; or
(2) That an employer pay all or part of the cost of family coverage that includes a dependent as provided pursuant to this subparagraph.
(c) A subscriber that elects family coverage during any applicable open enrollment period may enroll any dependent eligible pursuant to this subparagraph.
(d) Coverage for a dependent provided pursuant to this subparagraph shall be provided until the earlier of the following:
(1) The dependent is disqualified for dependent status as set forth in subparagraph I(3)(a); or
(2) The date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber.
(e) Nothing in this subparagraph shall be construed to permit a health insurance carrier to refuse an election for coverage by a dependent pursuant to subparagraph (c), based upon the dependent's prior disqualification pursuant to subparagraph (d)(1).
(f) Notice regarding coverage for a dependent as provided pursuant to this subparagraph shall be provided to a subscriber:
(1) In the certificate of coverage prepared for subscribers on or about the date of commencement of coverage; and
(2) Within 30 days following the effective date of this subparagraph. Such notice shall include information regarding the required special open enrollment period.
(3-a)(a) The coverage of any family member insured by such policy, pursuant to subparagraph (3), who is mentally or physically incapable of earning his or her own living on the date as of which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another policy as long as such incapacity continues and as long as said dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of said dependent, provided that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this subparagraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G;
(b) If the coverage for dependent children under subparagraph (3) includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this subparagraph. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this subparagraph. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this subparagraph commences; and
(4) The style, arrangement and over-all appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any indorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point (the "text" shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and
(5) The exceptions and reductions of indemnity are set forth in the policy, and, except those which are set forth in RSA 415:6, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "Exceptions," or "Exceptions and Reductions," provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and
(6) Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and
(7) It contains no provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the commissioner; and
(8) Wherever such policy provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of osteopathy, chiropractic, podiatry, optometry, or licensed as an advanced practice registered nurse, said policy contains a provision for reimbursement for such service when performed by a person so licensed.
(9) Notwithstanding any provisions in any such policy or contract for the provision of health care services or benefits provided by any health, medical or other service corporation licensed by the state, whenever the terms "physician" or "doctor" are used in any such policy or contract, said terms shall include within their meaning those persons licensed under RSA 317-A in respect to any care, services, procedures or benefits covered by said policy or contract which the persons so licensed are authorized to perform.
(10) It also conforms to the relevant provisions of RSA 420-G.
II. If any policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the commissioner that any such policy is not subject to approval or disapproval by such official, the commissioner may by ruling require that such policy meet the standards set forth in paragraph I of this section and in RSA 415:6.
III. Nonrenewable, individual health insurance policies which provide medical, hospital, or major medical expense benefits for a specified term may be delivered or issued for delivery to any person in this state for purposes of providing short-term, interim coverage only and no such policy shall provide coverage for a specified term in excess of 6 months, nor shall any such policy be issued in this state to a person who was previously covered under short-term medical policies providing in total more than 540 days of coverage within the preceding 24-month period.

Source. 1913, 226:2. PL 281:4. RL 331:4. 1951, 207:1, par. 4. RSA 415:5. 1969, 163:2; 271:1. 1973, 72:71. 1975, 111:1. 1985, 239:1. 1995, 112:5. 1997, 344:2. 2001, 112:1. 2006, 321:2. 2007, 352:1. 2009, 54:5; 177:1; 235:1, 2. 2010, 243:8, eff. Sept. 23, 2010.

Section 415:6

    415:6 Accident and Sickness Policy Provisions. –
I. Required Provisions. Except as provided in paragraph III of this section each such policy delivered or issued for delivery to any person in this state shall contain the provisions specified in this paragraph in the words in which the same appear in this section; provided, however, that the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary. Such provisions shall be preceded individually by the caption appearing in this paragraph or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.
(1) A provision as follows: Entire Contract; Changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.
(2) A provision as follows: Time Limit on Certain Defenses:
(a) After 2 years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such 2-year period.
(The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 2-year period, nor to limit the application of RSA 415:6, II(1)-(5) in the event of misstatement with respect to age or occupation or other insurance.)
(A policy which the insured has the right to continue in force subject to its terms by the timely payment of premium (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue, may contain in lieu of the foregoing the following provision (from which the clause in parentheses may be omitted at the insurer's option) under the caption "Incontestable": After this policy has been in force for a period of 2 years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.)
(b) No claim for loss incurred or disability (as defined in the policy) commencing after 2 years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.
(3) A provision as follows: Grace Period: A grace period of __________ (insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.
(A policy which contains a cancellation provision may add at the end of the above provision,
subject to the right of the insurer to cancel in accordance with the cancellation provision hereof.
A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision,
Unless not less than 5 days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted,).
(4) A provision as follows: Reinstatement: If any renewal premium is not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained on or after the date of reinstatement and loss due to such sickness as may begin on or after the date of reinstatement. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.
(The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue.)
(4-a) With respect to policies subject to RSA 420-G, a provision as follows: Reinstatement: If any renewal premium is not paid within the time granted the insured for payment, a subsequent payment of the premium to the insurer or to any agent duly authorized by the insurer to receive such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a receipt for the premium tendered, the policy will be reinstated upon receipt of such application by the insurer or such agent. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained on or after the date of reinstatement and loss due to sickness as may begin on or after the date of reinstatement. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.
(The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue.)
(5) A provision as follows: Notice of Claim: Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at __________ (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.
(In a policy providing a loss-of-time benefit which may be payable for at least 2 years, an insurer may at its option insert the following between the first and second sentences of the above provision: Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least 2 years, he shall, at least once in every 6 months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of 6 months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured's right to any indemnity which would otherwise have accrued during the period of 6 months preceding the date on which such notice is actually given.)
(6) A provision as follows: Claim Forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.
(7) A provision as follows: Proofs of Loss: Written proof of loss must be furnished to the insurer at its office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the insurer is liable and in case of claim for any other loss within one year after the date of such loss in the case of a Medicare supplement insurance policy and within 90 days after the date of such loss in the case of any other accident and health insurance policy. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.
(8) A provision as follows: Time of Payment of Claims: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ___ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.
(9) A provision as follows: Payment of Claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.
(The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:
If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $ ___ (insert an amount which shall not exceed $1000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.
Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.)
(10) A provision as follows: Physical Examinations and Autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.
(11) A provision as follows: Legal Actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.
(12) A provision as follows: Change of Beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.
(The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer's option.)
(13) A provision as follows: Loss of Time Benefits: If loss of time benefits payable to the insured are reduced by reason of benefits payable to the insured under the federal Social Security Act, such benefits shall not be further reduced by reason of any increase in benefits payable under the federal Social Security Act which takes effect after the first month that benefits are payable for a period of disability; except that if benefits under the policy are provided on a specified dollar amount basis, then such benefits shall not be further reduced by reason of any increase in benefits payable under the federal Social Security Act which takes effect after the effective date of the policy.
(14) Refund upon cancellation: After the policy has been continued beyond its original term, the insured may cancel the policy at any time by written notice, delivered or mailed to the insurer or the insurer's representative. Such cancellation shall become effective upon receipt by the insurer or the insurer's representative, or on such later date as may be specified in such notice by the insured. If the insured cancels, the insurer shall promptly return any unearned portion of the premium paid, but in any event shall return the unearned portion of the premium within 30 days. The earned premium shall be computed on a pro-rata basis. Cancellation shall be without prejudice to any claim originating prior to the effective date of the cancellation.
(15) A provision as follows: Pre-certification: In the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.
II. Other Provisions. Except as provided in paragraph III of this section, no such policy delivered or issued for delivery to any person in this state shall contain provisions respecting the matters set forth below unless such provisions are in the words in which the same appear in this section; provided, however, that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in this paragraph or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.
(1) A provision as follows: Change of Occupation: If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.
(2) A provision as follows: Misstatement of Age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.
(3) A provision as follows: Other Insurance in This Insurer: If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for ___(insert type of coverage or coverages) in excess of $ ___ (insert maximum limit of indemnity or indemnities) the excess insurance shall be void and all premiums paid for such excess shall be returned to the insured or to his estate.
or, in lieu thereof:
Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.
(4) A provision in all nongroup policies as follows: Insurance with Other Insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or an expense incurred basis, payment shall not be prorated or reduced. If such a case, the insured shall be entitled to payment from both insurers. Provided, however, that the provisions of this subparagraph shall not prohibit the issuance of a "benefits deductible" on policies determined by the insurance commissioner as major medical policies. The term "benefits deductible", as used herein, means the value of any benefits provided on an expense incurred basis which are provided with respect to covered medical expenses by any other hospital, surgical or medical insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan, or any other plan or program whether on an insured or uninsured basis. Provided, however, that the term "benefits deductible" shall not mean the value of benefits provided with respect to medical or liability insurance offered under either a general liability insurance policy or an auto insurance policy.
(5) A provision in all non-group policies as follows: Insurance with Other Insurers: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis, payment shall not be prorated or reduced. In such a case, the insured shall be entitled to payment from both insurers.
(6) A provision as follows: Relation of Earnings to Insurance: If the total monthly amount of loss time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of 2 years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such 2 years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $200 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.
(The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at least 5 years from its date of issue. The insurer may, at its option, include in this provision a definition of "valid loss of time coverage," approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the commissioner or any combination of such coverages. In the absence of such definition such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute (including any workers' compensation or employer's liability statute), or benefits provided by union welfare plans or by employer or employee benefit organizations.
(7) A provision as follows: Unpaid Premium: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.
(8) A provision as follows: Cancellation; Refusal to Renew: The insurer may refuse to renew on the policy anniversary date, or may cancel this policy at any time by written notice delivered to the insured, or mailed to the insured's last address as shown by the records of the insurer, stating when, not less than 30 days thereafter, such cancellation or refusal to renew shall be effective. If the insurer cancels, the earned premium shall be computed pro-rata. Cancellation or refusal to renew shall be without prejudice to any claim originating prior to the effective date of the cancellation or refusal to renew. However, such cancellation or refusal to renew, if for reasons other than nonpayment of premium and other than specified in any time limits for certain defenses, shall be effected only if also effected on all policyholders of the same class. No such action shall be taken without prior written approval of the insurance commissioner. The insurer shall have the burden of proof that the classification of risk involved therein is reasonable and nondiscriminatory, pursuant to RSA 415:15.
(9) A provision as follows: Conformity with State Statutes: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.
III. Inapplicable or Inconsistent Provisions. If any provision of this section is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the commissioner, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.
IV. Order of Certain Policy Provisions. The provisions which are the subject of paragraphs I and II of this section, or any corresponding provisions which are used in lieu thereof in accordance with such paragraphs shall be printed in the consecutive order of the provisions in such paragraphs or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.
V. Third Party Ownership. The word "insured," as used in this chapter, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.
VI. Requirements of Other Jurisdictions.
(1) Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this chapter and which is prescribed or required by the law of the state under which the insurer is organized.
(2) Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.
VII. Filing Procedure. The commissioner may make such reasonable rules and regulations concerning the procedure for the filing or submission of policies subject to this chapter as are necessary, proper or advisable to the administration of this chapter. This provision shall not abridge any other authority granted the commissioner by law.

Source. 1913, 226:3. PL 281:5, 8. RL 331:5, 8. 1951, 207:1, par. 5. RSA 415:6. 1971, 553:1. 1973, 471:1, 2. 1975, 333:1; 494:2, 3. 1983, 474:1. 1990, 194:1. 1993, 167:1, 2. 1995, 112:6-8. 2007, 289:1, eff. Jan. 1, 2008.

Section 415:6-a

    415:6-a Insurance Contracts; Welfare Recipients. – No accident or health insurance policy issued, renewed or continued after August 28, 1981 shall contain any provision denying or limiting insurance benefits because services are rendered to an insured or a dependent who is eligible for or who receives medical assistance under RSA 167 or RSA 161.

Source. 1981, 502:2, eff. Aug. 28, 1981.

Section 415:6-aa

    415:6-aa 90-Day Supply of Covered Prescription Drugs. – An insurer issuing or renewing accident and health insurance policies shall allow its insureds to purchase an up-to-90-day supply of covered prescription drugs on the covered person's health plan formulary at one time at a pharmacy of the insured's choice within the insurer's network, provided that the insured can demonstrate that such drug has been taken by the insured for a continuous period of one year and provided that such drug is not subject to the health plan's utilization management, prior authorization, or pre-certification requirements. Controlled substances as identified by the United States Drug Enforcement Administration are exempt from this section. Nothing in this section shall be construed to limit the health plan's ability to establish co-payments, coinsurance deductibles, or other member cost shares. A retail pharmacy dispensing a 90-day supply of covered prescription drugs under this section shall comply with any specified terms, conditions, and reimbursement rate which the plan may require for mail order pharmacies that fill 90-day prescriptions.

Source. 2007, 73:1. 2014, 120:1, eff. Aug. 15, 2014.

Section 415:6-b

    415:6-b Coverage of Certain Psychiatric and Psychological Services. – No accident or health insurance policy issued, renewed or continued on or after January 1, 1993, shall contain any provision denying insurance benefits for psychiatric or psychological services, including psychological examinations, solely because they are rendered to an insured or a dependent in compliance with the lawful order of any court of this state. Benefits for such services shall be at least as favorable as for other psychiatric or psychological services, including psychological examinations, and shall be subject to the same dollar limits, deductibles, co-payments and co-insurance factors and to terms and conditions of the policy or certificate, including any managed care provisions.

Source. 1992, 177:1, eff. Jan. 1, 1993.

Section 415:6-c

    415:6-c Coverage for Nonprescription Enteral Formulas. –
I. Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance who are residents of this state, coverage for the provision of nonprescription enteral formulas for the treatment of impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, or motility of the gastrointestinal tract. Such coverage shall be provided when the prescribing physician has issued a written order stating that the enteral formula is needed to sustain life, is medically necessary, and is the least restrictive and most cost effective means for meeting the needs of the patient.
II. Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance who are residents of this state, coverage for the provision of nonprescription enteral formulas and food products required for persons with inherited diseases of amino acids and organic acids. Such coverage shall be provided when the prescribing physician has issued a written order stating that the enteral formula or food product is medically necessary and is the least restrictive and most cost effective means for meeting the needs of the patient. Coverage for inherited diseases of amino acids and organic acids shall, in addition to the enteral formula, include food products modified to be low protein in an amount not to exceed $1,800 annually for any insured individual.
III. The benefits included in this section shall not be subject to any greater deductible than any other benefits provided by the insurer. The coinsurance required by the enrolled participant shall not exceed the amount allowed under the contract for the reasonable and customary charge for the service provided.

Source. 1996, 131:1, eff. July 20, 1996.

Section 415:6-d

    415:6-d Maternity Rider. – Upon issuing any individual health insurance policy providing hospital, medical-surgical or major medical benefits, an insurer shall offer the insured the option of including a maternity benefits rider if maternity care is not covered under the policy. Nothing in this section shall be construed to apply to supplemental health insurance and disability insurance policies.

Source. 1996, 188:19, eff. Jan. 1, 1997.

Section 415:6-e

    415:6-e Coverage for Diabetes Services and Supplies. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for medically appropriate and necessary outpatient self-management training and educational services, pursuant to a written order of a primary care physician or practitioner, including but not limited to medical nutrition therapy for the treatment of diabetes, provided by a certified, registered, or licensed health care professional with expertise in diabetes, subject to the terms and conditions of the policy. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses which provides a prescription rider shall cover medically appropriate or necessary insulin, oral agents, and equipment used to treat diabetes subject to the terms and conditions of the policy. Each insurer that provides coverage for prescription insulin drugs shall cap the total amount that a covered person is required to pay for each covered insulin drug prescription at an amount not to exceed $30 for each 30-day supply of each insulin prescription. The maximum $30 copayment for each 30-day supply of each covered insulin drug prescription shall apply when an original prescription is dispensed as well as when refills of the prescription are dispensed, including early refills. Coverage for prescription insulin drugs shall not be subject to any deductible. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses which provides for durable medical equipment coverage shall provide coverage for medically appropriate or necessary equipment used to treat diabetes subject to the terms and conditions of the policy.

Source. 1997, 258:1, eff. Jan. 1, 1998. 2020, 13:1, eff. Sept. 14, 2020.

Section 415:6-f

    415:6-f Patients' Bill of Rights. – Any insurer issuing an individual policy under this chapter shall provide to each new policyholder who is a resident of this state a copy of the patients' bill of rights law under RSA 151:21.

Source. 1997, 331:13, eff. Aug. 22, 1997.

Section 415:6-g

    415:6-g Off-Label Prescription Drugs. –
I. No insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses and providing coverage for prescription drugs shall:
(a) Exclude coverage for any such drug for a particular indication on the ground that the drug has not been approved by the Food and Drug Administration (FDA) for that indication, if such drug is recognized for treatment of such indication in one of the standard reference compendia or in the medical literature; or
(b) As a condition of coverage, impose use of an alternative drug not approved by the FDA for the indication being treated, unless such alternative drug is recognized for treatment of such indication in one of the standard reference compendia or in the medical literature. An override of such condition of coverage shall be expeditiously granted consistent with RSA 420-J:7-b, II whenever the prescriber can demonstrate that the alternative drug:
(1) Has been ineffective in the treatment of the insured's medical condition in the past;
(2) Is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen;
(3) Will cause or will likely cause an adverse reaction or other physical harm to the insured; or
(4) Is not in the insured's best interest, based on medical necessity consistent with RSA 420-J:7-b, II.
II. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.
III. Nothing in this section requires:
(a) Coverage for any drug if the FDA has determined its use to be contraindicated for the treatment of the particular indication for which the drug has been prescribed;
(b) Coverage for experimental or investigational drugs not approved for any indication by the FDA; and
(c) Reimbursement or coverage for any drug not included on the drug formulary or list of covered drugs specified in a health plan, contract, or policy.

Source. 1999, 323:2. 2014, 226:1, eff. Sept. 12, 2014.

Section 415:6-h

    415:6-h Prompt Payment Required. –
I. (a) Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses for its insured persons shall pay for services rendered by New Hampshire health care providers within 30 calendar days upon receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.
(b) When the insurer is denying or pending the claim, the insurer shall have 15 calendar days upon receipt of an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or certificate holder of the reason for denying or pending the claim and what, if any, additional information is required to adjudicate the claim. Upon the insurer's receipt of the requested additional information, the insurer shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).
(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The insurer shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.
(d) The insurer's failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.
II. In this section:
(a) "Clean claim" means a claim for payment of covered health care expenses that is submitted to an insurer on the insurer's standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the insurer's published filing requirements.
(b) "Electronic claim" means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the insurer and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be in compliance with such act.
III. Any initial clean claim submission not paid within the time periods specified in subparagraph I(a) shall be deemed overdue. In that case:
(a) The insurer shall pay the health care provider or the insured person the amount of the overdue claim plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and
(b) The health care provider may recover from the insurer, upon a judicial finding of bad faith, reasonable attorney's fees for advising and representing a health care provider in a successful action against an insurer for payment of the claim.
IV. Exceptions to the requirements of this section are as follows:
(a) No insurer shall be in violation of this section for a claim submitted by a health care provider if:
(1) Failure to comply is caused by a directive from a court or a federal or state agency;
(2) The insurer is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or
(3) The insurer's compliance is rendered impossible due to matters beyond the insurer's control which are not caused by such insurer.
(b) No insurer shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.
(c) No insurer shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review process.
V. The commissioner may assess an administrative fine against any insurer or may suspend or revoke the license or certificate of authority of any insurer after determining that the insurer has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall not exceed $300,000 per calendar year examined. Nothing in this paragraph shall be construed to alter the commissioner's authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.

Source. 2000, 274:2; 314:2. 2005, 162:1. 2009, 235:3, eff. Sept. 14, 2009.

Section 415:6-i

    415:6-i Retroactive Denials Prohibited; Exceptions. –
I. In this section, "retroactive denial of a previously paid claim" means any attempt by an insurer to retroactively collect payments already made to a health care provider with respect to a claim by requiring repayment of such payments, reducing other payments currently owed to the provider, withholding or setting off against future payments, or reducing or affecting the future claim payments to the provider in any other manner.
II. No insurer shall impose on any health care provider any retroactive denial of a previously paid claim or any part thereof unless:
(a) The insurer has provided the reason for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the date of payment of the challenged claim does not exceed 12 months. The retroactive denial of a previously paid claim may be permitted beyond 12 months from the date of payment only for the following reasons:
(1) The claim was submitted fraudulently;
(2) The claim payment was incorrect because the health care provider or the insured was already paid for the health care services identified in the claim;
(3) The health care services identified in the claim were not delivered by the health care provider;
(4) The claim payment was for services covered by Title XVIII, Title XIX, or Title XXI of the Social Security Act;
(5) The claim payment is the subject of an adjustment with a different insurer, administrator, or payor and such adjustment is not affected by a contractual relationship, association, or affiliation involving claims payment, processing, or pricing; or
(6) The claim payment is the subject of legal action.
III. An insurer shall notify a health care provider at least 15 days in advance of the imposition of any retroactive denials of previously paid claims. The health care provider shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service. Notwithstanding the contractual terms between the insurer and provider, the insurer shall allow for the submission of a claim that was previously denied by another insurer due to the insured's transfer or termination of coverage.

Source. 2002, 143:1. 2006, 104:1, eff. Aug. 7, 2006. 2018, 317:1, eff. Jan. 1, 2019.

Section 415:6-j

    415:6-j Coverage for Certain Prosthetic Devices. –
I. Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance who are residents of this state, coverage for the provision of benefits for prosthetic devices under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section.
II. In this section, "prosthetic device" means an artificial limb device to replace, in whole or in part, an arm or leg.
III. An insurer shall not impose any annual or lifetime dollar maximum on coverage for prosthetic devices other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy.
IV. An insurer shall not apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the policy other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy.

Source. 2003, 216:2, eff. Jan. 1, 2004.

Section 415:6-k

    415:6-k Individual Policy Prescription Drug Information Cards. –
I. Each insurer that issues or renews any individual policy of accident or health insurance which provides coverage for prescription drugs or devices or which contracts with an entity providing such prescription drug coverage, including but not limited to pharmacy benefit manager companies, shall issue to certificate holders a card or other technology containing uniform prescription drug information. The uniform prescription drug information card or technology shall include all of the fields required by the health insurance provider for claims processing in a clear, readable, and understandable manner on the card or other technology issued, shall include the information required under RSA 400-A:15-c, and shall include, at a minimum, the following information:
(a) The name or trademark logo of the insurer and, if another company administers the prescription benefit, the name or trademark logo of the benefit administrator.
(b) The certificate holder's name and identification number.
(c) All of the electronic transaction routing information required by the insurer or its benefit administrator in order for the pharmacy to electronically process a prescription claim, including but not limited to the BIN number labeled as such or the Processor Control Number labeled as such, or both.
II. All subscriber health insurance cards issued after January 1, 2004 shall contain the information required under paragraph I.
III. A new uniform prescription drug information card, as required under this section, shall be issued by an insurer upon enrollment of new members and when reissuing a new card to current members when there is a change in the certificate holder's pharmacy coverage that affects data contained on the card.

Source. 2003, 286:2, eff. Sept. 16, 2003. 2016, 111:1, eff. Jan. 1, 2017.

Section 415:6-l

    415:6-l Coverage for Certified Midwives; Individual. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing maternity benefits, shall also provide to certificate holders of such insurance, who are residents of this state, coverage consistent with the terms and conditions of the policy for services rendered by a midwife certified under RSA 326-D. Such coverage shall be subject to each insurer's standards and mechanisms for credentialing and contracting pursuant to RSA 420-J:4 and RSA 420-J:8 respectively, where applicable, and contingent upon services being provided in a licensed health care facility or at home and within the scope of practice of a certified midwife. Benefits provided shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2006, 8:1. 2008, 298:1, eff. Aug. 27, 2008.

Section 415:6-m

    415:6-m Coverage for the Cost of Testing for Bone Marrow Donation. –
I. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state and who meet the criteria for testing as established by the Match Registry (the National Marrow Donor Program), coverage for laboratory fee expenses up to $150 arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for utilization in bone marrow transplantation. The testing shall be performed in a facility that is accredited by the American Association of Blood Banks or its successors, or the College of American Pathologists, or its successors, or any other national accrediting body with requirements that are substantially equivalent to or more stringent than those of the College of American Pathologists, and is licensed under the Clinical Laboratory Improvement Act of 1967, 42 U.S.C. section 263a, as amended. At the time of the new testing, the person tested shall complete and sign an informed consent form that also authorizes the results of the test to be used for participation in the National Marrow Donor Program and shall acknowledge a willingness to be a bone marrow donor if a suitable match is found.
II. In addition to paragraph I, the testing facility shall not bill, charge, collect a deposit from, seek payment or reimbursement from, or have recourse against a covered person or a person acting on behalf of the covered person for any portion of the laboratory fee expenses.

Source. 2006, 187:1. 2011, 133:5, eff. Jan. 1, 2012.

Section 415:6-n

    415:6-n Coverage for Children's Early Intervention Therapy Services. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical, rehabilitation, or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for expenses arising from the services of licensed and credentialed occupational therapists, physical therapists, speech-language pathologists, and clinical social workers working with children from birth to 36 months of age with an identified developmental disability and/or delay as specified in rules adopted pursuant to RSA 171-A:18, IV as long as the providing therapist receives a referral from the child's primary care provider if applicable. The benefits in this section shall not be subject to deductibles, copayments, or coinsurance; provided that the benefits included in this section may have a cap of $3,200 per child per year not to exceed $9,600 by the child's third birthday. For a health care contract that meets the definition of a "high deductible plan" set forth in 26 U.S.C. section 223(c)(2) or a catastrophic health plan, as defined under the Patient Protection and Affordable Care Act of 2009, a carrier shall be exempt from the deductible provisions of this section and may apply a deductible to children's early intervention therapy services until an enrollee's deductible has been satisfied for the year. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall apply to the medical assistance program, pursuant to RSA 161 and RSA 167.

Source. 2007, 338:1, eff. Sept. 14, 2007. 2020, 26:39, eff. Sept. 18, 2020. 2021, 56:8, eff. July 24, 2021.

Section 415:6-o

    415:6-o Coverage for Obesity and Morbid Obesity; Individual. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for the diseases and ailments caused by obesity and morbid obesity and treatment for such, including bariatric surgery, when the prescribing physician has issued a written order stating that treatment is medically necessary and in accordance with the patient qualifications and treatment standards set forth by the American Society for Metabolic and Bariatric Surgery or the American College of Surgeons. Such treatment standards may include, but not be limited to, pre-operative psychological screening and counseling, behavior modification, weight loss, exercise regimens, nutritional counseling, and post-operative follow-up, overview, and counseling of dietary, exercise, and lifestyle changes. The covered insured shall be at least 18 years of age. The benefits included in this section shall be subject to the terms and conditions of the policy and shall be no less extensive than coverage provided for similar conditions or illnesses.

Source. 2008, 389:1, eff. Sept. 14, 2008.

Section 415:6-p

    415:6-p Coverage for Hearing Aids. –
Each insurer that issues or renews any individual policy or certificate for delivery in this state, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide coverage for the professional services associated with the practice of fitting, dispensing, servicing, or sale of hearing instruments or hearing aids. The benefits included in this section shall not be subject to any greater deductible or coinsurance or copay than any other benefits provided by the insurer. Insurers are required to cover the cost of a hearing aid for each ear, as needed, as well as related services necessary to assess, select, and fit the hearing aid with a maximum for the hearing aid and related services of no less than $1,500 per hearing aid every 60 months. The insured may choose a higher price hearing aid and pay the difference in cost. The hearing aid shall be prescribed and dispensed by a licensed audiologist or hearing instrument specialist. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall not apply to the medical assistance program, pursuant to RSA 161 and RSA 167. In this section:
I. "Hearing care professional" means a person who is a licensed audiologist, a licensed hearing instrument dispenser, or a licensed physician.
II. "Hearing instrument" or "hearing aid" means any instrument or device designed, intended, or offered for the purpose of improving a person's hearing and any parts, attachments, or accessories, including earmolds. Batteries, cords, and individual or group auditory training devices and any instrument or device used by a public utility in providing telephone or other communication services are excluded.
III. "Hearing instrument dispenser" means a person who is a hearing care professional that engages in the selling, practice of fitting, selecting, recommending, dispensing, or servicing of hearing instruments or the testing for means of hearing instrument selection or who advertises or displays a sign or represents himself or herself as a person who practices the testing, fitting, selecting, servicing, dispensing, or selling of hearing instruments.
IV. "Practice of fitting, dispensing, servicing, or sale of hearing instruments" means the measurement of human hearing with an audiometer, calibrated to the current American National Standard Institute standards, for the purpose of making selections, recommendations, adoptions, services, or sales of hearing instruments including the making of earmolds as a part of the hearing instrument.

Source. 2010, 362:1, eff. Jan. 1, 2011.

Section 415:6-q

    415:6-q Reimbursement for Ambulance Service Providers. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance that constitutes health coverage under RSA 420-G:2, IX, and that provides benefits for medically necessary ambulance services shall reimburse the ambulance service provider directly or by a check payable to the insured and the ambulance service provider subject to the terms and conditions of the policy, plan, or contract. Nothing in this section shall preclude an insurer from negotiating with and subsequently entering into a contract with a non-participating ambulance provider that establishes rates of reimbursement for emergency medical services.

Source. 2011, 133:1, eff. Jan. 1, 2012.

Section 415:6-r

    415:6-r Naturopathy Providers; Payment for Equivalent Types of Service; Individual. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses shall provide to persons covered by such insurance who are residents of this state coverage for expenses arising from a health service performed by a doctor of naturopathic medicine licensed under RSA 328-E if that particular type of service is within the scope of practice of such doctor and if the insurer would reimburse for that type of service when performed by any other type of health care provider. Such coverage shall be subject to each insurer's standards and mechanisms for determining medical necessity, for credentialing pursuant to RSA 420-J:4, and for contracting pursuant to RSA 420-J:8. Benefits provided shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2012, 278:1, eff. Jan. 1, 2013.

Section 415:6-s

    415:6-s Repealed by 2014, 299:8, I, eff. Oct. 1, 2017. –

Section 415:6-t

    415:6-t Oral Anti-Cancer Therapies. –
I. No insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for anti-cancer medications that are injected or intravenously administered by a health care provider and patient administered anti-cancer medications, including but not limited to those orally administered or self-injected, shall require a higher copayment, deductible, or coinsurance amount for patient administered anti-cancer medication than it requires for injected or intravenously administered anti-cancer medications, regardless of the formulation or benefit category determination by the policy or plan.
II. An insurer shall not comply with paragraph I by:
(a) Increasing the copayment, deductible, or coinsurance amount required for injected or intravenously administered anti-cancer medication that are covered under the policy or plan.
(b) Reclassifying benefits with respect to anti-cancer medications.
III. In this section, "anti-cancer medication" means drugs and biologics that are used to kill, slow, or prevent the growth of cancerous cells.
IV. If the cost-sharing requirements for orally administered anti-cancer medications do not exceed $200 per prescription fill, the health plan shall be deemed in compliance with this section.
V. For a health care contract that meets the definition of a "high deductible plan" set forth in 26 U.S.C. section 223(c) (2), a carrier shall be exempt from the provisions of paragraphs I-IV until an enrollee's deductible has been satisfied for the year.
VI. This section shall apply only to oral anti-cancer medications where an intravenously administered or injected anti-cancer medication is not medically appropriate.
VII. This section shall not apply to policies which are solely to replace income or pay a predetermined fixed amount based on the occurrence of a specified medical or health event.

Source. 2015, 263:6, eff. Jan. 1, 2017.

Section 415:6-u

    415:6-u Coverage for Early Refills of Prescription Eye Drops. –
I. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for one early refill of a prescription for eye drops if the following criteria are met:
(a) For prescription eye drops dispensed as a 30-day supply, the enrollee requests the refill no earlier than 21 days after the later of the following dates:
(1) The date the original prescription was dispensed to the enrollee; or
(2) The date that the most recent refill of the prescription was dispensed to the enrollee;
(b) For prescription eye drops dispensed as a 90-day supply, the enrollee requests the refill no earlier than 63 days after the later of the following dates:
(1) The date the original prescription was dispensed to the enrollee; or
(2) The date that the most recent refill of the prescription was dispensed to the enrollee;
(c) The prescribing health care provider indicated on the original prescription that a specific number of refills are authorized;
(d) The refill requested by the enrollee does not exceed the number of refills indicated on the original prescription;
(e) The prescription has not been refilled more than once during the 30-day or 90-day period prior to the request for an early refill; and
(f) The prescription eye drops are a covered benefit under the enrollee's health plan.
II. Benefits provided under this section shall not be subject to any greater copayment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2016, 326:1, eff. Aug. 23, 2016.

Section 415:6-v

    415:6-v Coverage for Blood Lead Testing. – Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses shall provide to persons covered by such insurance who are residents of this state coverage for the costs of blood lead testing conducted pursuant to RSA 130-A:5-a. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2018, 4:11, eff. Feb. 8, 2018.

Section 415:6-w

    415:6-w Coverage for Prescription Contraceptive Drugs and Prescription Contraceptive Devices and for Contraceptive Services. – Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for outpatient contraceptive services under the same terms and conditions as for other outpatient services. "Outpatient contraceptive services" means consultations, examinations, and medical services, provided on an outpatient basis, including the initial screening provided through a pharmacy pursuant to RSA 318:47-l at a rate established by contract between the pharmacy and the insurer or its pharmacy benefits manager, and related to the use of contraceptive methods to prevent pregnancy which have been approved by the U.S. Food and Drug Administration. Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses shall cover all prescription contraceptive drugs and contraceptive devices approved by the U.S. Food and Drug Administration. Coverage shall include contraceptives dispensed in a quantity intended to last for a 12-month period if prescribed in that quantity. An insurer shall not impose utilization review requirements or other limitations to control the prescribing or dispensing of contraceptives to an amount that is less than a 12-month supply, if that quantity is prescribed. An insurer shall not be required to cover more than one 12-month contraceptive prescription in a single dispensing per plan year. A deductible, copayment, coinsurance, or other cost-sharing requirement shall not be imposed on the coverage of prescription contraceptive drugs and contraceptive devices approved by the FDA under this section. Notwithstanding any other provision of law, if there is a therapeutic equivalent of a drug or device for an FDA-approved contraceptive method, an insurer may impose cost-sharing requirements as long as at least one drug or device for that method is available without cost-sharing; provided that if an individual's provider recommends a particular FDA-approved contraceptive drug or device based on a medical determination, the insurer shall provide coverage for the prescribed contraceptive drug or device without cost-sharing. Nothing in this section shall be construed as altering the terms and conditions of a contract relating to prescription drugs and outpatient services. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall apply to the medical assistance program, pursuant to RSA 161 and RSA 167.

Source. 2018, 205:7, eff. Jan. 1, 2019; 361:8, eff. Jan. 1, 2019 at 12:01 a.m.

Section 415:6-x

    415:6-x Coverage for Medically Necessary Dental Services. – Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for medically necessary dental services resulting from an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Treatment made necessary due to injury to the jaw and oral structures other than teeth shall be covered without time limit. Coverage under this section shall be subject to such other terms and conditions of the policy that may apply.

Source. 2019, 113:1, eff. Aug. 20, 2019.

Section 415:6-y

    415:6-y Coverage for Perfluoroalkyls (PFAS) and Perfluorinated Compound (PFC) Blood Testing. – Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for perfluoroalkyls (PFAS) and perfluorinated compound (PFC) blood testing. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2020, 30:9, eff. Sept. 21, 2020.

Section 415:6-z

    415:6-z Coverage for Epinephrine Auto-Injectors. – Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for the cost of epinephrine auto-injectors. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer and shall be subject to the terms and conditions of the policy. In this section, "epinephrine auto-injector" means a single-use device used for the automatic injection of a pre-measured dosage of epinephrine into the human body.

Source. 2020, 13:9, eff. Jan. 1, 2021.

Section 415:6-a1

    415:6-a1 Coverage for Long-Term Antibiotic Therapy for Tick-Borne Illness. – Each insurer that issues or renews any individual policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for long-term antibiotic therapy for tick-borne illness when determined to be medically necessary and ordered by a licensed infectious disease physician after making a thorough evaluation of the patient's symptoms, diagnostic test results or response to treatment. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer. In this section, "long-term antibiotic therapy" means the administration of oral, intramuscular, or intravenous antibiotics singly or in combination, for periods of time in excess of 4 weeks.

Source. 2020, 39:20, eff. June 30, 2021.

Section 415:7

    415:7 Conforming to Statute. –
I. Other Policy Provisions. No policy provision which is not subject to RSA 415:6 shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to this chapter.
II. Policy Conflicting With This Chapter. A policy delivered or issued for delivery to any person in this state in violation of this chapter shall be held valid but shall be construed as provided in this chapter. When any provision in a policy subject to this chapter is in conflict with any provision of this chapter, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this chapter.

Source. 1913, 226:5, 9. PL 281:13, 19. RL 331:13, 19. 1951, 207:1, par. 6, eff. July 1, 1951.

Section 415:8

    415:8 Exceptions. – A policy, rider or endorsement, which could have been lawfully used or delivered or issued for delivery to any person in this state immediately before July 1, 1951, may be used or delivered or issued for delivery to any such person during 5 years after July 1, 1951, without being subject to the provisions of RSA 415:5-415:7, 415:13, 415:14 and 415:16.

Source. 1951, 207:5, eff. July 1, 1951.

Section 415:9

    415:9 Falsity in Application. – The falsity of any statement in the application for any policy covered by this chapter shall not bar the right to recovery thereunder, unless such false statement was made with actual intent to deceive, or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer.

Source. 1913, 226:6. PL 281:15. RL 331:15.

Section 415:10

    415:10 Acknowledgment of Notice. – The acknowledgment by any insurer of the receipt of notice given under any policy covered by this chapter, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder, shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

Source. 1913, 226:7. PL 281:16. RL 331:16.

Section 415:11

    415:11 Alteration of Application. – No alteration of any written application for insurance, by erasure, insertion or otherwise, shall be made by any person other than the applicant without his written consent, and the making of any such alteration without the consent of the applicant shall be a misdemeanor.

Source. 1913, 226:8. PL 281:17. RL 331:17.

Section 415:12

    415:12 By Insurer. – If such alteration shall be made by any officer of the insurer, or by any employee of the insurer with the insurer's knowledge or consent, such act shall be deemed to have been performed by the insurer thereafter issuing the policy upon such altered application.

Source. 1913, 226:8. PL 281:18. RL 331:18.

Section 415:13

    415:13 Age Limit. – If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

Source. 1951, 207:2, par. 19, eff. July 1, 1951.

Section 415:14

    415:14 Non-Application to Certain Policies. – Except as otherwise specifically provided, nothing in this chapter shall apply to or affect (1) any policy of workers' compensation insurance or any policy of liability insurance with or without supplementary coverage therein; or (2) any policy or contract of reinsurance; or (3) any blanket or group policy of insurance; or (4) life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to accident and sickness insurance as (a) provide additional benefits in case of death or dismemberment or loss of sight by accident, or as (b) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled, as defined by the contract or supplemental contract.

Source. 1913, 226:10. PL 281:20. RL 331:20. 1951, 207:2, par. 20. RSA 415:14. 1955, 128:1, eff. May 9, 1955.

Section 415:15

    415:15 Discrimination. – Discrimination between individuals of the same class in the amount of premiums or rates charged for any policy of insurance covered by this chapter, or in the benefits payable thereon, or in any of the terms or conditions of such policy, or in any other manner whatever, is prohibited. Discrimination on the basis of gender identity with respect to the availability of any covered services, medications, supplies, or durable medical equipment is specifically prohibited.

Source. 1913, 226:11. PL 281:21. RL 331:21. 2019, 332:19, eff. Jan. 1, 2020.

Section 415:16

    415:16 Approval by Commissioner. – No supplemental contract referred to in paragraph (4) of RSA 415:14 shall be issued or delivered to any person in this state until a copy of the form thereof has been submitted to, and approved by, the commissioner, under such reasonable rules and regulations as he shall make concerning the provisions in such contracts and their submission to and approval by him.

Source. 1913, 226:12. PL 281:24. RL 331:24. 1951, 207:3, eff. July 1, 1951.

Section 415:17

    415:17 Fraternal Benefit Societies. – This chapter shall not apply to or in any way affect fraternal benefit societies.

Source. 1913, 226:12. PL 281:25. RL 331:25.

Section 415:18

    415:18 General Group or Blanket Policy Provisions. –
I. Policies, certificates and other forms attached to group or blanket accident or health insurance, or accident and health insurance, shall comply with all applicable laws, including RSA 420-G, and with rules adopted by the commissioner. No such policy or certificate shall be delivered or issued for delivery in this state to a resident of this state without the prior written approval of the commissioner. The commissioner shall adopt rules, pursuant to RSA 541-A, establishing conditions by which insurers may deem such policies or certificate forms approved upon the expiration of a 30-day period following the commissioner's receipt of the insurer's submission of the policy and certificate forms for approval. No policy of group or blanket accident or health insurance, or accident and health insurance affecting a resident of New Hampshire, whether such policy is delivered or issued for delivery in this state or any other state, and no certificate thereunder shall, except as provided in paragraph III of this section, be delivered or issued for delivery in this state unless the policy or certificate contains in substance each and all of the provisions set forth in the following subparagraphs or provisions which in the opinion of the commissioner are more favorable to the holders of such certificates or not less favorable to the holders of such certificates and more favorable to policyholders:
(a) A provision that no statement made by the applicant for insurance shall avoid the insurance or reduce benefits thereunder unless contained in the written application signed by the applicant; and a provision that no agent has authority to change the policy or to waive any of its provisions; and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer.
(b) A provision that all statements contained in any such application for insurance shall be deemed representations and not warranties.
(c) A provision that all new employees or new members, as the case may be, in the groups or classes eligible for such insurance must be added to such groups or classes for which they are respectively eligible.
(d) A provision that all premiums due under the policy shall be remitted by the employer or employers of the persons insured or by some other designated person acting on behalf of the association or group insured, to the insurer on or before the due date thereof, with such grace period as may be specified therein.
(e) A provision stating the conditions under which the insurer may decline to renew the policy.
(f) A provision that the insurer shall issue to the employer or other person or association in whose name such policy is issued, for delivery to each member of the insured group, an individual certificate setting forth in summary form a statement of the essential features of the insurance coverage of such employee or such member, to whom the benefits thereunder are payable, and in substance the provisions of subparagraphs (g) to (s) inclusive.
(g) A provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages.
(h) A provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.
(i) A provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within one year after the date of such loss in the case of a group Medicare supplement insurance policy or certificate and within 90 days after the date of such loss in the case of any other group accident and health insurance policy or certificate. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.
(j) A provision that the insurer will furnish to the policyholder such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished before the expiration of 15 days after the insurer receives notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made.
(k) A provision that the insurer shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.
(l) A provision that all benefits payable under the policy other than benefits for loss of time will be payable not more than 60 days after receipt of proof, and that, subject to due proof of loss all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.
(m) A provision that indemnity for loss of life of the insured is payable to the beneficiary if surviving the insured, and otherwise to the estate of the insured; and that all other indemnities of the policy are payable to the insured, except as provided in paragraph IV of this section; and that if a beneficiary is designated, the consent of the beneficiary shall not be requisite to change of beneficiary, or to any other changes in the policy or certificate, except as may be specifically provided by the policy.
(n) A provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within 3 years from the expiration of the time within which proof of loss is required by the policy.
(o) A provision that if loss of time benefits payable to the holder of the certificate are reduced by reason of benefits payable to the holder of the certificate under the federal Social Security Act, such benefits shall not be further reduced by reason of any increase in benefits payable under the federal Social Security Act which takes effect after the first month that benefits are payable for a period of disability; except that if benefits under the policy are provided on a specified dollar amount basis, then such benefits shall not be further reduced by reason of any increase in benefits payable under the federal Social Security Act which takes effect after the effective date of the policy.
(p) A provision that the policyholder is entitled to a grace period of 31 days for the payment of any premium due except the first, during which grace period the coverage shall continue in force, unless the policyholder has given the insurer written notice of discontinuance in advance of the period for which payment is due, and in accordance with the terms of the policy. The policy may provide that the policyholder shall be liable to the insurer for the payment of a portion of the premium corresponding to the time within the grace period during which the policy was in force.
(q) A provision that the insurer shall not exclude part-time employees and shall offer the same group health benefits to part-time employees as it offers to the employee groups of which the part-time employees would be members if they were full-time employees. The insurer shall offer to include the part-time employees as part of the employer's employee group, at the full rate to be paid by the employer, at a rate prorated between the employer and the employee, or at the employee's expense. A part-time employee shall be any employee who regularly works at least half of the weekly hours of the full-time employee in the employee group of which the part-time employee would be a member if he were a full-time employee, but who works a minimum of at least 15 hours per week. An insurer, however, may exclude part-time employees from eligibility for group health coverages providing disability or income replacement benefits, whether short- or long-term.
(r) A provision that the validity of the policy shall not be contested except for nonpayment of premiums, after it has been in force for 2 years from its date of issue; and that no statement made by any person covered under the policy relating to insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of 2 years during such person's lifetime, nor unless it is contained in a written instrument signed by the person making such statement. No such provision, however, shall preclude the assertion, at any time, of defenses based upon the person's ineligibility for coverage under the policy or upon other provisions in the policy, except for any provisions establishing, as a requirement of eligibility, the furnishing of satisfactory evidence of insurability to the insurer.
(s) [Repealed.]
(t) A provisions as follows: Payment of Claims. Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured. (The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:
(1) If any indemnity of this policy or certificate shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $ (insert an amount which shall not exceed $1,000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.
(2) Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy or certificate on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.)
(u) A provision that in the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.
I-a. "Blanket accident and health insurance" means that form of accident and health insurance that is not "health coverage" under RSA 420-G:2, IX, that does not require individual applications from covered persons, and that does not require a carrier to furnish each person with a certificate of coverage. Blanket health coverage shall be issued only to the following groups and cover only the following defined persons in the groups:
(a) A common carrier, which shall be deemed the policyholder, and which shall cover a group defined as all or any of the class of persons who may become passengers on such a common carrier.
(b) An employer, which shall be deemed the policyholder, and which shall cover all employees or any subset of employees defined solely by reference to exceptional hazards incident to such employment.
(c) A volunteer fire department, first aid, or other such volunteer group, which shall be deemed the policyholder, and which shall cover all the members of such department or group.
(d) A sports team or a camp, which team or camp shall be deemed the policyholder and which shall cover all members or campers.
(e) A travel agency, or other organization that provides travel-related services, which organization shall be deemed the policyholder and which shall cover all persons for whom travel-related services are provided. Notwithstanding anything herein to the contrary, blanket accident and health coverage for travel-related services issued to a travel agency or to an organization that provides travel-related services may require individual applications or enrollment forms from covered persons and premium payments from covered persons, and the carrier may furnish each covered person with a summary of benefits.
(f) A school, institution of higher education, or other educational organization, which shall be deemed the policyholder and which shall cover all persons who are students, employees, or unpaid volunteers performing services for the policyholder.
I-b. The benefits payable under blanket accident and health insurance shall not be assigned to a health care provider.
II. Any portion of any policy of group or blanket accident or health insurance affecting a resident of New Hampshire, whether such policy is delivered in this state or any other state, and any certificate under such policy, which purports, by reason of the circumstances under which a loss is incurred, to reduce any benefits promised thereunder to an amount less than that provided for the same loss occurring under ordinary circumstances, shall be printed, in such policy and in each certificate issued under such policy, in boldface type and with greater prominence than any other portion of the text of such policy or certificate, respectively; and all other exceptions of the policy shall be printed in the policy and in the certificate, with the same prominence as the benefits to which they apply.
III. The commissioner may approve any form of blanket accident or health or accident and health insurance policy, or any form of certificate to be issued under such policy, which omits or modifies any of the provisions hereinbefore required, if he deems such omission or modification suitable for the character of such insurance and not unjust to the persons insured thereunder.
IV. Any such group policy may include benefits payable on account of hospital or medical or surgical aid for an employee or other member of the group insured by such policy, his or her spouse, child or children or other dependents, and may provide that any such benefits be paid by the insurer directly to the hospital, physician, surgeon, doctor, nurse or other person furnishing services covered by such provision of said policy.
IV-a. [Repealed.]
V. (a) The coverage of any dependent of any employee or member of the group insured by such policy, pursuant to paragraph IV, who is mentally or physically incapable of earning his or her own living on the date as of which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another group policy as long as such incapacity continues and as long as said dependent remains chiefly financially dependent on the employee or member of the group or the employee or his or her estate is chargeable for the care of said dependent, provided that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this paragraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G.
(b) If the coverage for dependent children under paragraph IV includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this subparagraph. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this subparagraph. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this subparagraph commences.
VI. Notwithstanding any provision of any policy of insurance issued under the provisions of this section, whenever such policy provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of osteopathy, chiropractic, podiatry, optometry, or licensed as an advanced practice registered nurse, reimbursement under such policy shall not be denied when such service is rendered by a person so licensed.
VII. (a) If a group policy affecting a resident of New Hampshire is delivered or issued for delivery in this state or any other state, and such policy provides hospital or surgical expense insurance or major medical expense insurance for other than specific diseases, accidents only, or student major medical expense coverage insurance where the policyholder is the school, the policy and any certificate issued under such policy to a New Hampshire resident shall contain a provision to the effect that in case of termination for any reason whatever of coverage, including termination of eligibility for continuation coverage, provided any employee while insured under a group policy issued to his or her employer, if the employee or member is not then covered by another policy of hospital or surgical expense insurance or hospital service or medical expense indemnity corporation subscriber contract providing similar benefits or if the employee or member is not covered by or eligible to be covered by a group contract or policy providing similar benefits or is not provided with similar benefits required by any statute or provided by any welfare plan or program, the employee or member, if he or she has been insured under the group policy for at least 60 days, shall be entitled to have issued to him or her by the New Hampshire high risk pool without evidence of insurability upon application to the New Hampshire high risk pool within 31 days after such termination and upon payment of the applicable premium, an individual policy of insurance under RSA 404-G or shall be entitled to elect the 39-week extension period pursuant to RSA 415:18, XVII.
(b) The effective date of the individual policy shall be the date of the termination of the individual's insurance under the group policy. The individual policy shall not exclude any other preexisting condition.
(c) The option to obtain coverage from the New Hampshire high risk pool under RSA 404-G shall also be available, upon the death of the employee or member, to the surviving spouse with respect to those family members who are then covered by the group policy, to a child solely with respect to himself or herself upon his or her attaining the limiting age of coverage under the group policy while covered as a dependent thereunder, and to a former dependent spouse upon remarriage of the group plan member. The option to obtain coverage from the New Hampshire high risk pool shall be exercised within 31 days of the qualifying event.
(d) Each certificate holder in the insured group shall be given written notice of the option and its duration within 30 days after the date of termination of the group contract or policy. Such notice shall be mailed by the insurer to the certificate holder at the last address furnished to the insurer by the contract holder at the same time as the notice required by RSA 415:18, XVII is mailed. Each certificate holder shall have the option of electing an individual policy from the New Hampshire high risk pool under RSA 404-G, or the 39-week extension period provided pursuant to RSA 415:18, XVII. The election of the 39-week extension period upon termination by any person or member shall not preclude such person or member from electing to exercise the option of obtaining coverage from the New Hampshire high risk pool under RSA 404-G at the expiration of the 39-week extension period.
VII-a. Any employee whose compensation includes group hospital or surgical expense insurance or major medical expense insurance for other than specific diseases or accidents only the premiums for which are paid in full or in part by an employer including the state of New Hampshire, its political subdivisions, or municipal corporations, or paid by payroll deduction, may pay the premiums as they become due directly to the policyholder whenever the employee's compensation is suspended or terminated directly or indirectly as the result of a strike, lockout, or other labor dispute for a period not exceeding 6 months and at the rate and coverages as the policy provides.
(a) During said 6-month period, the policy may not be altered or changed, except that nothing in this section shall be deemed to impair the right of the insurer to make normal decreases or increases of the premium rate upon expiration and renewal of the policy, in accordance with the provisions of the policy.
(b) When the employee's compensation is so suspended or terminated, the employee shall be notified immediately by the policyholder in writing, by mail addressed to the address last on record with the policyholder, that the employee may pay the premiums to the policyholder as they become due as provided in this section.
(c) The policyholder shall remit any premiums paid by the employees on a timely basis to the insurer.
(d) Nothing herein shall be deemed to require the continuation of any such group coverage to any individual employee beyond the time that he takes full-time employment with another employer; nor shall anything herein be deemed to require continuation of the group coverage more than 6 months after compensation is suspended or terminated as the result of a labor dispute, nor to require the insurer to continue coverage as to any employee for whose coverage premiums have not been remitted in accordance with the provisions of the policy.
(e) After the 6-month period, the employee shall have the right to continue the benefits being continued under this paragraph for an additional 12 months as if the employee originally had elected the extension period provided by RSA 415:18, XVI and subject to the same conditions. At the end of the additional 12 months, the employee shall have the right, if the group insurance coverage is no longer available, to obtain coverage from the high risk pool.
(f) The provisions of this paragraph shall apply to group hospital and medical expense policies subject to RSA 415 and group health service plan contracts issued pursuant to RSA 420-A, and to health maintenance organization policies and plans issued pursuant to RSA 420-B.
VII-b. Any group accident and health insurance policy covering a resident of New Hampshire shall contain the following provisions:
(a) Upon a final decree of divorce or legal separation, if one spouse is a member of a group accident and health insurance policy, the former spouse who is a family member or eligible dependent under said policy prior to the date of the decree shall be and remain eligible for group benefits as a family member or eligible dependent under said policy, without additional premium or examination, as if said decree had not been issued. Such eligibility shall not be required if the decree expressly provides otherwise.
(b) The former spouse shall be eligible for coverage pursuant to this section through the member's participation in a group accident and health insurance policy, while such policy remains in force or is replaced by another group policy covering the member, until the earliest of the following events occurs:
(1) The 3-year anniversary of the final decree of divorce or legal separation;
(2) The remarriage of the former spouse;
(3) The remarriage of the member;
(4) The death of the member; or
(5) Such earlier time as provided by the final decree of divorce or legal separation.
(c) Upon the occurrence of the earliest of the events set forth in subparagraph (b), other than remarriage of the former spouse, the former spouse shall have the right to continuation coverage under RSA 415:18, XVI. An insurance carrier may charge a premium for the former spouse's continuation coverage under this subparagraph, in accordance with RSA 415:18, XVI. The former spouse shall request enrollment under RSA 415:18, XVI, in writing, within 30 days after the first occurring of the events set forth in subparagraph (b), provided that the former spouse may not request enrollment upon remarriage of the former spouse. If the first occurring event is the member's remarriage or death, the former spouse may request enrollment under RSA 415:18, XVI, in writing, within 30 days after receiving notice of said event.
(d) In the event of the former spouse's remarriage, the former spouse shall notify the insurance carrier, in writing, within 30 days after the date of remarriage, and the effective date of termination of the former spouse's eligibility pursuant to this section shall be the date of remarriage.
(e) The member or former spouse shall submit to the insurance carrier evidence of the former spouse's eligibility under this section within 30 days after the final decree of divorce or legal separation. If the group accident and health insurance policy existing as of the date of the decree is replaced by another group policy covering the member that is issued by a different insurance carrier, said carrier may request that the member or former spouse submit evidence of the former spouse's eligibility under this section within 30 days of the effective date of the member's coverage under the replacement policy. A former spouse's coverage under the member's group accident and health insurance policy pursuant to this section shall be effective as of the date of the final decree of divorce or legal separation in the case of a then existing policy, or, in the case of a replacement policy, the effective date of the member's coverage under such policy.
(f) The former spouse shall notify the insurance carrier, in writing, of any address other than the member's address to which notices and correspondence pertaining to the former spouse's coverage should be mailed, including but not limited to notice of cancellation and any right to reinstate coverage, and the carrier shall use such address until it receives written notice from the former spouse of a change.
(g) Upon termination of the eligibility of a former spouse for group coverage pursuant to this section, said former spouse may apply for individual coverage or the high risk pool, whichever is applicable.
(h) Eligibility of a former spouse for group coverage pursuant to this section exists independent of any right to continuation of coverage under RSA 415:18, XVI. To the extent that there is a conflict between this paragraph and RSA 415:18, XVI with respect to eligibility for group coverage upon a final decree of nullity, divorce or legal separation, the provisions that confer greater rights on the former spouse shall apply unless the decree expressly provides otherwise.
VIII. Notwithstanding any provision of any policy of insurance issued under the provisions of this section, whenever the terms "physician" or "doctor" are used in any such policy, said terms shall include within their meaning those persons licensed under RSA 317-A in respect to any care, services, procedures or benefits covered by said policy which the persons so licensed are authorized to perform.
IX. [Repealed.]
X. [Repealed.]
XI. [Repealed.]
XII. No insurer shall, when issuing or renewing a group policy or contract of hospital or surgical expense or major medical expense insurance or any certificate under such policy or contract covered by this chapter, deny coverage or limit coverage to any resident of this state and who is principally employed in this state and to any other person who is a non-resident but who is principally employed in this state on the basis of health risk or condition except that a waiting period consistent with insurance department rules may be imposed for pre-existing medical conditions. If an insurer accepts an application for group hospital or surgical expense or major medical expense coverage, such acceptance shall be subject to the following:
(a) If the group has coverage in effect through another plan, the insurer shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the insurer shall accept all persons for which the group seeks coverage.
(b) Once a group policy has been issued, any person becoming eligible for coverage shall become covered by enrolling within 31 days after first becoming eligible. Any person so enrolling shall not be required to submit evidence of insurability based on medical conditions. If a person does not enroll at this time, he is a late enrollee.
(c) Once a group policy has been issued, the insurer shall provide the group with an annual open enrollment period for late enrollees. During the open enrollment period, any late enrollee shall be permitted to enroll without submitting any evidence of insurability based on medical conditions. For late enrollees in a large employer group only, the pre-existing condition provisions shall apply for 18 months from the date of enrollment. However, an eligible employee or dependent shall not be considered a late enrollee if the individual:
(1) Was covered under a public or private health insurance or other health benefit arrangement at the time the individual was eligible to enroll; and
(2) Has lost coverage under a public or private health insurance or other health benefit arrangement as a result of termination of employment or eligibility, the termination of the other plan's coverage, death of a spouse, or divorce; and
(3) Requests enrollment within 60 days after termination of coverage provided under a public or private health insurance or other health benefit arrangement; or
(i) The individual is employed by an employer which offers multiple health benefit plans and the individual elects a different plan during an open enrollment period; or
(ii) A court has ordered coverage to be provided for an ex-spouse or minor child under a covered employee's health benefit plan and request for enrollment is made within 30 days after issuance of such court order.
XIII. An insurer issuing policies of group insurance shall allocate the costs associated with maternity and childbirth over both males and females covered by its entire block of business in this state. In cases in which, because of the amount written in the state, allocation to an entire block of business needs to occur, the carrier may apply for a waiver from the insurance commissioner.
XIV. An insurer issuing policies of group insurance shall provide to each new certificate holder who is a resident of this state a copy of the patients' bill of rights law under RSA 151:21.
XV. In paragraphs XVI and XVII:
(a) "Carrier" means an entity that offers or provides a policy, contract, or certificate of insurance coverage in this state. "Carrier" shall include an insurer, a health maintenance organization, or any other entity providing a policy, contract, or certificate of insurance coverage subject to state insurance regulation.
(b) "Cancellation" means the circumstance when the employer/employee relationship ceases to exist.
(c) "Individual" means any person covered under a group health plan, including but not limited to, the covered employee, the spouse of the covered employee, whether surviving, dependent, former dependent, divorced or legally separated; or the dependent child of the employee, and any other person including a child born or placed for adoption with the covered employee, who is covered under a group health plan through the employment relationship.
(d) "Health insurance" means all group hospital and medical expense policies subject to RSA 415, group health service plan contracts pursuant to RSA 420-A, and health maintenance organization policies and plans issued pursuant to RSA 420-B, and all other plans that are additionally subject to RSA 420-G, except for small employers of size one defined pursuant to RSA 420-G:2, XVI.
(e) "Entire group termination" means that circumstance when all health insurance coverage to the group ends.
XVI. Continuation of Coverage.
(a) Carriers shall provide continuation of coverage when an individual covered by a plan of group health insurance or a health maintenance organization that provides medical, hospital, dental, and/or surgical expense benefits, except student major medical expense coverage where the policyholder is the school, loses coverage under the plan. Any group policy of health insurance that affects a resident of New Hampshire that is delivered or issued for delivery in this state or any other state shall contain a provision that allows each subscriber or member on the policy who is a resident of New Hampshire to obtain continuation coverage under this section. Coverage shall be provided in accordance with the procedures described in this section.
(b) Continuation coverage shall be identical to the coverage provided to other similarly situated members of the group that are still covered by the plan. The policy shall not be changed from the underlying group coverage, except that normal premium rate increases or decreases upon renewal affecting the group plan may also affect the continuation premium rate. The effective date of continuation coverage shall be the date the individual's coverage under the group plan ceased.
(c) Periods of coverage shall be as follows:
(1) Eighteen month period-When any individual loses coverage under a group health insurance plan for any reason except dismissal from employment for gross misconduct or carrier termination, coverage shall continue subject to this section for a period of 18 months, unless the individual is eligible for coverage under subparagraphs (2), (3), (4), or (5).
(2) Thirty-nine week period (entire group insurance termination)-Whenever the entire group is terminated, coverage shall continue subject to this section for a period of 39 weeks. Where an individual has continuation coverage, coverage shall continue until it would have expired had the plan not been terminated or for 39 weeks, whichever occurs first.
(3) Twenty-nine month period (disability)-An individual who is determined to be disabled within the first 60 days of the date such individual loses coverage shall be entitled to 29 months of continuation coverage. Determination of disability shall be under Title II or XVI of the federal Social Security Act or any future act that has the same purpose.
(4) Thirty-six month period-Subject to subparagraph (e), coverage shall continue subject to this section for a period of 36 months if any individual loses coverage under a group health insurance plan for one of the following reasons:
(A) Death of a covered employee;
(B) The divorce or the legal separation of the covered employee or, if the employee's former spouse has been covered pursuant to RSA 415:18, VII-b, the first occurring of any of the following events:
(i) The remarriage of the covered employee;
(ii) The death of the covered employee;
(iii) The 3-year anniversary of the final decree of divorce or legal separation; or
(iv) Such earlier time as provided by said decree;
(C) A substantial loss of coverage by retirees and dependents within one year of the employer filing for protection under the bankruptcy provisions of Title 11 of the United States Code; or
(D) A dependent child ceasing to be a dependent child.
(5) When the surviving spouse, divorced spouse, or legally separated spouse is 55 years of age or older and loses coverage because of the death, divorce, or legal separation of the covered employee, coverage shall continue subject to this section until such time as the spouse becomes eligible for participation in another employer-based group plan or becomes eligible for Medicare.
(d) Premium Payments. When an individual's coverage has ended, the amount of the premium charged to the individual electing continuation coverage shall not exceed 102 percent of the group premium amount as allocated for that individual's coverage.
(e) Responsibilities.
(1) When an individual loses coverage, it shall be the responsibility of the carrier to notify the individual of the right to elect continuation coverage.
(2) It shall be the responsibility of the individual electing continuation coverage to make timely premium payments. A 30-day grace period for payment of the premium shall be provided. Failure to make a timely remittance of the premium shall be grounds for cancellation. Whenever a carrier fails to notify an individual that his or her coverage will not continue unless the individual so elects, the carrier shall be liable, in accordance with the terms of the policy, for claims accrued until such notice is made, except that any carrier that in good faith mailed a notice to the last known address of the individual shall not be held liable. Such carrier's liability shall in no way diminish the liability of the employer if the employer fails to notify the carrier of a member's loss of coverage.
(f) Notice Requirements and Procedures. A carrier shall notify the members and subscribers of their continuation rights as follows:
(1) The carrier shall provide, at the time of commencement of coverage under the health benefit plan, a summary plan description to each eligible member or subscriber of the rights provided under this section.
(2) Notice of the right to continue coverage also shall be set forth in each master policy and individual certificate of coverage.
(3) When coverage for an individual will cease under the group policy, the carrier shall notify the individual of the individual's right to continue, the amount of the premium required to continue coverage, and the procedure for electing continuation coverage. The notice of continuation shall specify the election period that shall not be less than 45 days after the date of the notice and shall be mailed to the last known address of the individual provided by the employer or plan administrator.
(4) The carrier shall specify in each notice of continuation how premium payments are to be remitted.
(5) The carrier shall notify the individual of the right to continue coverage within 30 days of receiving notice from the plan administrator or employer of the loss of coverage.
(g) Election Requirements and Procedures.
(1) An individual electing continuation coverage shall notify the carrier in writing with a copy of the notice provided to the employer or plan administrator when the election is made. Such election shall be made within 45 days of the date of notice.
(2) Where the employee's spouse is also covered by the group plan, and there is a divorce or legal separation, the employee shall notify the employer of the divorce or separation within 30 days, and shall provide the employer and carrier with the employee's spouse's mailing address. In case of a divorce or legal separation, the carrier shall provide a separate notice of the right to continue to the divorced or separated spouse. The divorced or separated spouse may elect to continue coverage pursuant to this section by notifying the carrier within 45 days of the date of the notice and remitting the premium payment. The notice and election provisions of this paragraph shall also apply if the divorced or legally separated spouse of the employee has been covered pursuant to RSA 415:18, VII-b, upon the occurrence of any of the following events:
(A) The remarriage of the employee;
(B) The death of the employee;
(C) The 3-year anniversary of the final decree of divorce or legal separation; or
(D) Such earlier time as provided by the final decree of divorce or legal separation.
(3) Election by the individual shall be made within the period of time stated in the notice of the right to continue, by written notice to the carrier and the employer. The required premium payment, as specified in the notice of the right to continue, shall be remitted as required in the notice with the written notice of election.
(4) Where an individual declines the right to continue coverage pursuant to this section, waiver shall be made by an affirmative means of declination, including but not limited to written declination of continuation coverage or electronic contact to the employer or plan administrator. An individual shall have the right to revoke the notice of declaration anytime within the specified election period.
(5) Where proper notice has been given, and no response is made within the election period, coverage may be deemed waived if the carrier has in good faith made reasonable efforts to contact the eligible individual. However, no carrier may deem any coverage waived if a notice does not fully comply with this section.
(6) Where an individual has attempted to notify the carrier, employer, or plan administrator of election, and where the written election has not included a premium payment, the carrier shall allow the individual to comply by paying the full amount of the unpaid premiums within 30 days of the date of election.
(7) Where more than one person covered by the group health insurance plan will lose coverage as a result of the covered employee's termination from the group, each individual shall be provided with a notice and shall have the opportunity to elect or waive coverage. Where there is a choice among plans, each individual shall have the opportunity to choose a plan.
(8) An election of continuation of coverage by a subscriber shall be deemed to include an election of continuation coverage on behalf of any other of the subscriber's dependents or beneficiaries who would lose coverage under the health benefit plan.
(h) End of Continuation Coverage. Nothing in this paragraph shall require a carrier to continue coverage pursuant to this section beyond:
(1) The first day of the month following the individual's eligibility for a group plan through a different employer;
(2) In the case of an individual that is eligible for Medicare, the date of the first Medicare open enrollment period following the date the individual became ineligible for continued participation under the group plan;
(3) In the case of a period of extended coverage for a person who has been determined to be disabled during the first 60 days of continuation coverage, the month that begins more than 30 days after the date of a final determination that the person is no longer disabled;
(4) The date on which continuation coverage ceases because the individual has failed to pay the premium. The individual shall be given a 30-day grace period before coverage is cancelled, and shall be provided with a notice within 15 days of the date of termination that the coverage will be cancelled if the premium is not paid; or
(5) The date on which the group plan terminates subject to the continuation rights set forth in RSA 415:18, XVII.
(i) The provisions of this paragraph shall apply to group hospital and medical expense policies subject to RSA 415, group health service plan contracts issued pursuant to RSA 420-A, and to health maintenance organization policies and plans issued pursuant to RSA 420-B, and to group policies that cover New Hampshire residents who work in other states. The provisions of this section shall not apply to individuals covered under group policies issued to small employers of size one, as defined pursuant to RSA 420-G:2, XVI.
(j) Relationship to Federal Law. In any circumstance where more extensive notice requirements or other procedural requirements apply, the health benefit plan shall satisfy the specific requirements of federal law with respect to those procedural requirements.
XVII. Termination of Coverage.
(a) Whenever any group hospital, surgical, dental insurance plan, medical insurance plan, or health maintenance organization coverage terminates for any reason, the benefits of such plan shall be available at the same group rate to the covered members of the group plan, for an extension period of 39 weeks, or until such member of the group plan becomes eligible for benefits under another group plan, whichever occurs first.
(b) Written notice of the right to continue such group coverage upon termination shall be given by the carrier in each master policy, certificate, and group policy.
(c) Upon termination of the group policy for nonpayment of premiums the carrier shall give notice within 30 days of the effective date of termination of the policy to the policyholder and each certificate holder under the policy. Termination of the group policy for nonpayment of premiums shall occur no earlier than the date of expiration of the grace period, pursuant to RSA 415:18, I(p), for which premium was due but not paid. The notice shall provide that the certificate holder or policyholder may elect coverage from the date of termination to the date of notice; or elect coverage from the date of termination to the date of notice and continue such coverage in force pursuant to subparagraphs (d), (e), and (f).
(d) The member electing coverage under this subparagraph shall provide the carrier written notice of election together with the required premium contribution within 31 days of the date of the notice. The group rate shall be paid by the member directly to the carrier. The premium rate shall be that required for the coverage being continued and shall not exceed the applicable group rate, but a reasonable administrative fee not to exceed 2 percent of the monthly premium may be charged to offset billing and payment costs.
(e) If group members become entitled to the 39-week extension period due to termination of the policy, the carrier shall:
(1) Notify such person or member of the option to elect continuation of coverage for the extension period of 39 weeks and the conditions applicable to such coverage within 30 days of the date the plan terminates.
(2) If the carrier fails to notify the members of the termination of the group plan within 30 days of the date of termination of the group coverage, the members shall not be liable for any premiums that have not been paid prior to the date the notice was sent. In no event shall a person or member entitled to coverage for the extension period of 39 weeks be responsible for premiums accrued and unpaid prior to the date of the termination or cancellation of the coverage.
(3) Where coverage has ended as a result of an employer's nonpayment of premiums, the member electing continuation coverage shall not be liable for any accrued and unpaid premium that was the employer's responsibility under the policy, or any amount previously paid by the person for coverage under the policy that due to the employer's actions was not paid to the carrier.

Source. 1941, 110:2. RL 331:26. 1947, 141:1, 2. RSA 415:18. 1969, 163:1; 271:2. 1973, 445:1, 2. 1975, 111:2; 333:2; 500:1-3, 5. 1979, 418:3. 1981, 391:1. 1983, 473:16, VII. 1985, 239:2; 316:3. 1986, 93:1, 3; 114:1; 163:1, 6. 1990, 267:1-5. 1992, 222:1, 5, 6. 1993, 162:1-3; 196:1. 1994, 138:2, 3; 166:2-6. 1995, 112:9-13, 23, I. 1996, 188:3, 4. 1997, 190:6, 7; 331:14; 344:3. 1998, 85:1. 1999, 316:1, 2. 2001, 276:1, 2. 2002, 207:3, 4. 2006, 321:3. 2007, 289:2-7, 41; 379:3, 5-10. 2009, 54:5; 235:4, 5. 2010, 188:1, 5, 6, 13; 351:2. 2011, 189:5. 2012, 99:1, 4. 2014, 90:1, eff. Aug. 10, 2014. 2016, 111:2, eff. Jan. 1, 2017.

Section 415:18-a

    415:18-a Coverage for Mental or Nervous Conditions and Treatment for Chemical Dependency Required. –
I. (a) Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state and whose principal place of employment is in this state, coverage for expenses arising from the treatment of mental illnesses and emotional disorders which, in the professional judgment of:
(1) Psychiatrists;
(2) Licensed psychologists;
(3) Licensed pastoral psychotherapists;
(4) Psychiatric/mental health advanced practice registered nurses;
(5) Licensed clinical mental health counselors;
(6) Licensed alcohol and drug counselors;
(7) Licensed marriage and family therapists;
(8) Licensed clinical social workers; and
(9) Licensed, psychiatrist-supervised physician assistants
are subject to significant improvement through short-term therapy, and benefits for expenses arising from diagnosis and evaluation of all other mental illnesses and emotional disorders.
(b) Benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders shall be at least as favorable to the certificate holder as the minimum benefits specified in paragraphs II, III, and IV.
(c) Policies written pursuant to this section shall include coverage for expenses arising from treatment for chemical dependency, including alcoholism, up to a specified limit which may be defined in terms of a dollar amount or a maximum number of days or visits. Coverage for expenses arising from treatment for chemical dependency, including alcoholism, shall include both an inpatient and an outpatient benefit for detoxification and rehabilitation.
II. In the case of policies or certificates providing benefits for hospital expenses on other than a major medical basis, benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders based upon confinement in a licensed or accredited general hospital, including psychiatric inpatient facilities included under the license of such a hospital, shall be at least as favorable as benefits provided for any other illness in such a hospital. Benefits based upon confinement in a public mental hospital shall be at least as favorable as benefits provided for confinement in a licensed or accredited general hospital.
III. In the case of policies or certificates providing benefits for medical expenses on other than a major medical basis:
(a) Benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders for services of a psychiatrist, licensed psychologist, licensed pastoral psychotherapist, psychiatric/mental health advanced practice registered nurse, licensed clinical mental health counselor, licensed alcohol and drug counselor, licensed marriage and family therapist, licensed clinical social worker who customarily bills patients directly, or of a licensed, psychiatrist-supervised physician assistant whose billing goes through their place of employment, shall be subject to terms and conditions at least as favorable as those which apply to the benefits for the services of physicians for other illnesses. The ratio of the benefits to the fees reasonably and customarily charged for the services of such:
(1) Psychiatrists;
(2) Licensed psychologists;
(3) Licensed pastoral psychotherapists;
(4) Psychiatric/mental health advanced practice registered nurses;
(5) Licensed clinical mental health counselors;
(6) Licensed alcohol and drug counselors;
(7) Licensed marriage and family therapists;
(8) Licensed clinical social workers; or
(9) Licensed, psychiatrist-supervised physician assistants
shall be substantially the same as the ratio of the benefits for services of physicians for other illnesses to the fees reasonably and customarily charged for the services of such physicians for other illnesses.
(b) Each insurer, including health maintenance organizations pursuant to RSA 420-B, that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state and whose principal place of employment is in this state, benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders for services rendered at a community mental health center or psychiatric residential program approved by the department of health and human services. Those benefits shall be subject to terms and conditions at least as favorable as those which apply to the benefits for the treatment of other illnesses. The ratio of the benefits to the full reasonable charges for the services of such a center or program shall be substantially the same as the ratio of the benefits for services of physicians for other illnesses to the fees reasonably and customarily charged for the services of such physicians for other illnesses.
(c) Benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders for outpatient services rendered at a public mental hospital shall be subject to terms and conditions at least as favorable as those which apply to the benefits for the treatment of other illnesses. The ratio of the benefits to the fees reasonably and customarily charged for the services of such a hospital shall be substantially the same as the ratio of the benefits for services of physicians for other illnesses to the fees reasonably and customarily charged for the services of such physicians for other illnesses.
(d) Benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders for outpatient services under this paragraph need not be provided for the first or second visit providing such a limitation applies in the case of services for other illnesses. Benefits for outpatient treatment may be otherwise limited to not less than 15 full hours of treatment in any consecutive 12-month period.
IV. (a) In the case of policies or certificates providing benefits for hospital and medical expenses on a major medical basis, benefits arising from treatment, diagnosis and evaluation of mental illnesses and disorders shall be subject to deductibles and coinsurance at least as favorable as those which apply to the benefits for any other illness, provided that benefits payable for expenses incurred in any consecutive 12-month period may be limited to an amount not less than $3,000 per covered individual, and to a lifetime maximum of not less than $10,000 per covered individual.
(b) In this paragraph, covered major medical expenses include the reasonable charges for services and treatment on an inpatient, outpatient or partial hospitalization basis by:
(1) A psychiatrist;
(2) A licensed psychologist;
(3) A licensed pastoral psychotherapist;
(4) A psychiatric/mental health advanced practice registered nurse;
(5) A licensed clinical mental health counselor;
(6) A licensed alcohol and drug counselor;
(7) A licensed marriage and family therapist;
(8) A licensed clinical social worker;
(9) A licensed, psychiatrist-supervised physician assistant;
(10) A licensed general hospital;
(11) A public or licensed mental hospital; or
(12) A community mental health center or psychiatric residential program approved according to rules adopted by the commissioner of the department of health and human services.
IV-a. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses shall offer to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state and whose principal place of employment is in this state, the option of purchasing, for a separate and identifiable premium, additional coverage for expenses incurred as a result of treatment or counseling by a licensed clinical social worker.
V. In this section:
(a) "Psychiatrist" means a licensed physician who is board-certified or board-eligible according to the most recently promulgated regulations of the American Board of Psychiatry and Neurology.
(b) "Psychologist" means a person who:
(1) Is licensed under RSA 329-B as a psychologist;
(2) Is certified or licensed under a statute in another state which meets or exceeds the standards under RSA 329-B; or
(3) Is certified or licensed in another state and is listed in the National Register of Health Service Providers in Psychology.
(c) "Licensed pastoral psychotherapist" means an individual who is licensed as a pastoral psychotherapist under RSA 330-A and is a fellow or diplomat in the American Association of Pastoral Counselors.
(d) "Psychiatric/mental health advanced practice registered nurse" means an individual who is licensed as an advanced practice registered nurse in psychiatric mental health nursing under RSA 326-B:18, who is defined by and whose scope of practice is described under the rules adopted pursuant to RSA 326-B, and who is a licensed registered nurse, educationally prepared in nursing at a minimum of the master's level, and certified in the specialty by a recognized national certifying agency, such as the American Nurses Credentialing Center.
(e) "Licensed clinical social worker" means an individual who is licensed as a clinical social worker under RSA 330-A:18.
(f) "Licensed clinical mental health counselor" means an individual who is licensed as a clinical mental health counselor under RSA 330-A:19.
(g) "Licensed marriage and family therapist" means an individual who is licensed as a marriage and family therapist under RSA 330-A:21.
(h) "Licensed alcohol and drug counselor" means an individual who is licensed as an alcohol and drug counselor under RSA 330-C and is practicing solely within the scope of practice of a licensed alcohol and drug counselor.
(i) "Mental or nervous conditions" or "mental illness and emotional disorders" means mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" (DSM), excluding those disorders designated by a "V Code" and those disorders designated as criteria sets and axes provided for further study in the DSM. This term shall not include chemical dependency, including alcoholism.
(j) "Licensed, psychiatrist supervised physician assistant" means an individual who is licensed as a physician assistant under RSA 328-D whose supervising physician is a licensed psychiatrist.
VI. No services provided by a licensed pastoral psychotherapist to a member of his congregation in the course of the duties to which he has been called as a pastor, minister or staff person shall be covered under the provisions of this chapter. This limitation shall not apply to those licensed pastoral psychotherapists serving specifically and only as private, part-time consultants in pastoral psychotherapy to a parish under contract or otherwise for the purpose of providing services to individuals as a licensed pastoral psychotherapist. Nothing in this chapter shall be construed as allowing a parish, church or temple to provide religious ministrations to their parishioners or members under the provisions of this chapter which would normally be the responsibility of the clergy, religious or other religious staff duly called and employed by such congregations.
VII. No group policy or certificate subject to RSA 415:18-a issued, renewed or continued on or after January 1, 1993, shall contain any provision denying insurance benefits for psychiatric or psychological services, including psychological examinations, solely because they are rendered to an insured or a dependent in compliance with the lawful order of any court of this state. Benefits for such services shall be as favorable as for other psychiatric or psychological services, including psychological examinations, and shall be subject to the same dollar limits, deductibles, co-payments, and co-insurance factors and to terms and conditions of the policy or certificate, including any managed care provisions.
VIII. The commissioner may adopt rules, under RSA 541-A, as may be necessary to effectuate any provisions of the Mental Health Parity Act of 2008 that relate to the business of insurance.

Source. 1975, 349:1. 1976, 57:1. 1979, 293:1-5. 1981, 492:30; 569:18, 21. 1983, 291:1, I; 413:1, 2; 453:11. 1986, 105:1. 1991, 343:1. 1992, 177:2. 1994, 396:1-4, 11-14. 1995, 310:181, 182. 1998, 234:8-14. 1999, 272:5-8; 310:1-4. 2002, 204:1. 2003, 276:4. 2005, 293:13. 2009, 54:5; 235:6. 2010, 188:13. 2012, 233:7, eff. July 1, 2013. 2019, 278:9, eff. Sept. 17, 2019.

Section 415:18-b

    415:18-b Cancellation or Nonrenewal of Group Insurance Contracts. – No group accident or health insurance contract, authorized under this chapter, may be cancelled or nonrenewed by the insurer, except for nonpayment of premium, unless the group policyholder receives either a notice of cancellation or nonrenewal or an offer of renewal in accordance with this section. The notice of cancellation or nonrenewal or offer of renewal shall be delivered to the group policyholder or mailed to the group policyholder's last address as shown in the records of the insurer at least 45 days prior to the renewal date of the contract. Notice of cancellation for lack of participation, if permitted by the terms of the policy, shall be delivered to the group policyholder or mailed to the group policyholder's last address as shown in the records of the insurer, at least 30 days prior to the effective date of the cancellation.

Source. 1990, 194:2. 1991, 23:1, eff. Jan. 1, 1992.

Section 415:18-c

    415:18-c Repealed by 2010, 61:3, I, eff. May 18, 2010. –

Section 415:18-d

    415:18-d Coverage for Scalp Hair Prostheses. –
I. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses and which also provides coverage for other prostheses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state and whose principal place of employment is in this state, coverage for expenses for scalp hair prostheses worn for hair loss suffered as a result of alopecia areata, alopecia totalis, alopecia medicamentosa resulting from the treatment from any form of cancer or leukemia, or permanent loss of scalp hair due to injury. Such coverage, however, shall be subject to a written recommendation by the treating physician stating that the hair prosthesis is a medical necessity. Such coverage shall be subject to the same limitations and guidelines as other prostheses, provided, that such coverage for alopecia medicamentosa shall not exceed $350 per year.
II. For the purposes of this section:
(a) "Prostheses" means artificial appliances used to replace lost natural structures. Prostheses include, but are not limited to, artificial arms, legs, breasts or glass eyes.
(b) "Scalp hair prostheses" means artificial substitutes for scalp hair that are made specifically for a specific individual.

Source. 1992, 246:1. 2001, 276:3. 2010, 188:13, eff. Aug. 20, 2010.

Section 415:18-e

    415:18-e Coverage for Nonprescription Enteral Formulas. –
I. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the provision of nonprescription enteral formulas for the treatment of impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, or motility of the gastrointestinal tract. Such coverage shall be provided when the prescribing physician has issued a written order stating that the enteral formula is needed to sustain life, is medically necessary, and is the least restrictive and most cost effective means for meeting the needs of the patient.
II. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the provision of nonprescription enteral formulas and food products required for persons with inherited diseases of amino acids and organic acids. Such coverage shall be provided when the prescribing physician has issued a written order stating that the enteral formula or food product is medically necessary and is the least restrictive and most cost effective means for meeting the needs of the patient. Coverage for inherited diseases of amino acids and organic acids shall, in addition to the enteral formula, include food products modified to be low protein in an amount not to exceed $1,800 annually for any insured individual.
III. The benefits included in this section shall not be subject to any greater deductible than any other benefits provided by the insurer. The coinsurance required by the enrolled participant shall not exceed the amount allowed under the contract for the reasonable and customary charge for the service provided.

Source. 1995, 235:1. 1996, 131:2. 2010, 188:13, eff. Aug. 20, 2010.

Section 415:18-f

    415:18-f Coverage for Diabetes Services and Supplies. – Each insurer that issues or renews any policy, plan, or contract of group accident or health insurance providing benefits for medical or hospital expenses, shall provide each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for medically appropriate and necessary outpatient self-management training and educational services, pursuant to a written order of a primary care physician or practitioner, including but not limited to medical nutrition therapy for the treatment of diabetes, provided by a certified, registered, or licensed health care professional with expertise in diabetes, subject to the terms and conditions of the policy. Each insurer that issues or renews any group policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses which provides a prescription rider shall cover medically appropriate or necessary insulin, oral agents, and equipment used to treat diabetes subject to the terms and conditions of the policy. Each insurer that provides coverage for prescription insulin drugs shall cap the total amount that a covered person is required to pay for each covered insulin drug prescription at an amount not to exceed $30 for each 30-day supply of each insulin prescription. The maximum $30 copayment for each 30-day supply of each covered insulin drug prescription shall apply when an original prescription is dispensed as well as when refills of the prescription are dispensed, including early refills. Coverage for prescription insulin drugs shall not be subject to any deductible. Each insurer that issues or renews any group policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses which provides for durable medical equipment coverage shall provide coverage for medically appropriate or necessary equipment used to treat diabetes subject to the terms and conditions of the policy.

Source. 1997, 258:2. 2010, 188:13, eff. Aug. 20, 2010. 2020, 13:2, eff. Sept. 14, 2020.

Section 415:18-g

    415:18-g Coverage for Dental Procedures; Medical or Hospital; Group. –
I. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of New Hampshire, coverage for the medically necessary hospital or surgical day care facility charges and administration of general anesthesia administered by a licensed anesthesiologist or anesthetist for dental procedures performed on a covered person who:
(a) Is a child under the age of 13 who is determined by a licensed dentist in conjunction with a licensed physician to have a dental condition of significant dental complexity which requires certain dental procedures to be performed in a surgical day care facility or hospital setting; or
(b) Is a person who has exceptional medical circumstances or a developmental disability as determined by a licensed physician which place the person at serious risk.
II. All of the terms and conditions of the covered person's policy shall apply to these services.

Source. 1998, 280:2. 2003, 278:1. 2010, 188:13, eff. Aug. 20, 2010. 2018, 188:5, eff. Aug. 7, 2018.

Section 415:18-h

    415:18-h Coverage for Dental Procedures; Dental Offices. –
I. Each dental insurer or other similar entity, including Delta under RSA 420-F, that issues or renews any policy of group insurance providing benefits for oral surgical procedures, shall provide to each certificate holder who is a resident of New Hampshire coverage for the administration of general anesthesia administered by a licensed dentist for dental procedures performed in a dentist's office on a covered person who:
(a) Is a child under the age of 13 who is determined by a licensed dentist in conjunction with a licensed physician to have a dental condition of significant complexity which requires the child to receive general anesthesia for the treatment of such condition; or
(b) Is a person who has exceptional medical circumstances or a developmental disability as determined by a licensed physician which place the person at serious risk.
II. All of the terms and conditions of the covered person's policy shall apply to these services.

Source. 1998, 280:2. 2003, 278:2, eff. Jan. 1, 2004. 2018, 188:6, eff. Aug. 7, 2018.

Section 415:18-i

    415:18-i Coverage for Prescription Contraceptive Drugs and Prescription Contraceptive Devices and for Contraceptive Services. – Each insurer that issues or renews any group policy of accident or health insurance providing benefits for medical or hospital expenses, which provides coverage for outpatient services shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for outpatient contraceptive services under the same terms and conditions as for other outpatient services. "Outpatient contraceptive services" means consultations, examinations, and medical services, provided on an outpatient basis, including the initial screening provided through a pharmacy pursuant to RSA 318:47-l at a rate established by contract between the pharmacy and the insurer or its pharmacy benefits manager, and related to the use of contraceptive methods to prevent pregnancy which have been approved by the U.S. Food and Drug Administration. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses shall cover all prescription contraceptive drugs and prescription contraceptive devices approved by the U.S. Food and Drug Administration. Coverage shall include contraceptives dispensed in a quantity intended to last for a 12-month period, if prescribed in that quantity. An insurer shall not impose utilization review requirements or other limitations to control the prescribing or dispensing of contraceptives to an amount that is less than a 12-month supply, if that quantity is prescribed. An insurer shall not be required to cover more than one 12-month contraceptive prescription in a single dispensing per plan year. A deductible, copayment, coinsurance, or other cost-sharing requirement shall not be imposed on the coverage of prescription contraceptive drugs and contraceptive devices approved by the FDA under this section. Notwithstanding any other provision of law, if there is a therapeutic equivalent of a drug or device for an FDA-approved contraceptive method, an insurer may impose cost-sharing requirements as long as at least one drug or device for that method is available without cost-sharing; provided that if an individual's provider recommends a particular FDA-approved contraceptive drug or device based on a medical determination, the insurer shall provide coverage for the prescribed contraceptive drug or device without cost-sharing. Nothing in this section shall be construed as altering the terms and conditions of a contract relating to prescription drugs and outpatient services. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall apply to the medical assistance program, pursuant to RSA 161 and RSA 167.

Source. 1999, 252:1. 2010, 188:13, eff. Aug. 20, 2010. 2018, 205:4, eff. Jan. 1, 2019; 361:9, eff. Jan. 1, 2019 at 12:01 a.m.

Section 415:18-j

    415:18-j Off-Label Prescription Drugs. –
I. No insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses and providing coverage for prescription drugs shall:
(a) Exclude coverage for any such drug for a particular indication on the ground that the drug has not been approved by the Food and Drug Administration (FDA) for that indication, if such drug is recognized for treatment of such indication in one of the standard reference compendia or in the medical literature; or
(b) As a condition of coverage, impose use of an alternative drug not approved by the FDA for the indication being treated, unless such alternative drug is recognized for treatment of such indication in one of the standard reference compendia or in the medical literature. An override of such condition of coverage shall be expeditiously granted consistent with RSA 420-J:7-b, II whenever the prescriber can demonstrate that the alternative drug:
(1) Has been ineffective in the treatment of the insured's medical condition in the past;
(2) Is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen;
(3) Will cause or will likely cause an adverse reaction or other physical harm to the insured; or
(4) Is not in the insured's best interest, based on medical necessity consistent with RSA 420-J:7-b, II.
II. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.
III. Nothing in this section requires:
(a) Coverage for any drug if the FDA has determined its use to be contraindicated for the treatment of the particular indication for which the drug has been prescribed;
(b) Coverage for experimental or investigational drugs not approved for any indication by the FDA; and
(c) Reimbursement or coverage for any drug not included on the drug formulary or list of covered drugs specified in a health plan, contract, or policy.

Source. 1999, 323:6. 2010, 188:13. 2014, 226:2, eff. Sept. 12, 2014.

Section 415:18-k

    415:18-k Prompt Payment Required. –
I. (a) Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses for its insured persons shall pay for services rendered by New Hampshire health care providers within 30 calendar days upon receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim.
(b) When the insurer is denying or pending the claim, the insurer shall have 15 calendar days upon receipt of an electronic claim or 30 days upon receipt of a non-electronic claim to notify the health care provider or certificate holder of the reason for denying or pending the claim and what, if any, additional information is required to adjudicate the claim. Upon the insurer's receipt of the requested additional information, the insurer shall adjudicate the claim within 45 calendar days. If the required notice is not provided, the claim shall be treated as a clean claim and shall be adjudicated pursuant to subparagraph (a).
(c) Payment of a claim shall be considered to be made on the date a check was issued or electronically transferred. The insurer shall mail checks no later than 5 business days after the date a check was issued. Failure to mail a check within 5 business days shall constitute a violation subject to enforcement under RSA 415:20.
(d) The insurer's failure to comply with the time limits in this section shall not have the effect of requiring coverage for an otherwise non-covered claim. This section shall only apply to payments made on a claims basis and shall not apply to capitation or other forms of periodic payment.
II. In this section:
(a) "Clean claim" means a claim for payment of covered health care expenses that is submitted to an insurer on the insurer's standard claim form using the most current published procedural codes, with all the required fields completed with correct and complete information in accordance with the insurer's published filing requirements.
(b) "Electronic claim" means the transmission of data for purposes of payment of covered health care services in an electronic data format specified by the insurer and, if covered by the Health Insurance Portability and Accountability Act (HIPAA), is in such form and substance as to be in compliance with such act.
III. Any initial clean claim submission not paid within the time periods specified in subparagraph I(a) shall be deemed overdue. In that case:
(a) The insurer shall pay the health care provider or the insured person the amount of the overdue claim plus an interest payment of 1.5 percent per month beginning from the date the payment was due; and
(b) The health care provider may recover from the insurer, upon a judicial finding of bad faith, reasonable attorney's fees for advising and representing a health care provider in a successful action against an insurer for payment of the claim.
IV. Exceptions to the requirements of this section are as follows:
(a) No insurer shall be in violation of this section for a claim submitted by a health care provider if:
(1) Failure to comply is caused by a directive from a court or a federal or state agency;
(2) The insurer is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or
(3) The insurer's compliance is rendered impossible due to matters beyond the insurer's control which are not caused by such insurer.
(b) No insurer shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.
(c) No insurer shall be in violation of this section while the claim is pending due to a fraud investigation that has been reported to a state or federal agency, or an internal or external review process.
V. The commissioner may assess an administrative fine against any insurer or may suspend or revoke the license or certificate of authority of any insurer after determining that the insurer has established a pattern of overdue payments and that the contemplated enforcement action would not promote the deterioration of the financial condition of an at-risk insurer. Such fine shall not exceed $300,000 per calendar year examined. Nothing in this paragraph shall be construed to alter the commissioner's authority to investigate or take action, including, but not limited to, action pursuant to RSA 415:20, in response to individual instances of noncompliance.

Source. 2000, 274:3; 314:3. 2005, 162:2. 2009, 235:7. 2010, 188:13, eff. Aug. 20, 2010.

Section 415:18-l

    415:18-l Coverage Required for Qualified Clinical Trials. –
I. In this section:
(a) "Clinical trials of emerging technologies" mean Phase I and Phase II clinical trials.
(b) "Clinical trials of leading therapeutic or diagnostic alternatives" mean Phase III and Phase IV clinical trials.
(c) "Cooperative group" means a formal network of facilities that collaborate on research projects and have an established National Institute of Health (NIH) approved peer review program operating within the group.
(d) "FDA" means the federal Food and Drug Administration.
(e) "Member" means the policyholder, subscriber, insured, or certificate holder, or a covered dependent of a policyholder, subscriber, insured, or certificate holder.
(f) "Multiple project assurance contract" means a contract between an institution and the federal Department of Health and Human Services, that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.
(g) "NIH" means the National Institutes of Health.
(h) "Non-routine patient care cost" means:
(1) The cost of an investigational new drug or device that is not approved for market for any indication by the FDA.
(2) The cost of a non-health care service that a member may be required to receive as a result of the treatment being provided for the purposes of the clinical trial.
(3) The costs of services that are clearly inconsistent with widely accepted and established regional or national standards of care for a particular diagnosis.
(4) Costs associated with managing the research associated with the clinical trial.
(5) Non-covered costs under the member's policy, plan, or contract.
(i) "Routine patient care cost" means the cost of any medically necessary health care service that is incurred as a result of the treatment being provided to a member of a health plan. Routine costs are those for which the health plan regularly reimburses its members, health care providers, or health care institutions subject to the terms and conditions of the member's policy and the provider's service agreement with the insurer.
II. A policy, plan, or contract subject to this section shall provide coverage for all medically necessary routine patient care costs incurred as a result of a treatment being provided in accordance with a clinical trial to the extent such costs would be covered for noninvestigational treatments if the treatment is being provided or the studies are being conducted in a phase I, phase II, phase III, or phase IV clinical trial for cancer or the treatment is being provided for any other life-threatening condition. Coverage for phase I or phase II clinical trials shall be decided on a case by case basis.
III. The coverage required under paragraph II shall be required if:
(a) The treatment is being provided to the member in a clinical trial approved by:
(1) One of the National Institutes of Health;
(2) An NIH cooperative group or an NIH center;
(3) The FDA in the form of an investigational new drug application or exemption;
(4) The federal department of Veterans Affairs or Defense; or
(5) An institutional review board of an institution in this state that has a multiple assurance contract approved by the Office of Protection from Research Risks of the NIH.
(b) Standard treatment has been or would be ineffective, does not exist, or there is no superior non-investigational treatment alternative;
(c) The facility and personnel providing the treatment are capable of doing so by virtue of their experience, training, and volume of patients treated to maintain expertise; and
(d) The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the non-investigational alternative.
IV. A policy, plan, or contract subject to this section shall provide coverage for routine patient care costs incurred for drugs and devices provided to the member during the clinical trial, which are not the subject of the clinical trial, provided that those drugs or devices have been approved for sale by the FDA, whether or not the FDA has approved the drug or device for use in treating the member's particular condition. Nothing in this section shall be construed to abrogate the provisions of RSA 415:6-g or RSA 420-J:7-b. This coverage shall include coverage for reasonable and medically necessary services necessary to administer the drug or use the device under evaluation in the clinical trial.
V. The provisions of this section shall apply to group hospital and medical expense policies subject to RSA 415, health service corporations under RSA 420-A, health maintenance organizations under RSA 420-B, and managed care organizations under RSA 420-J.
VI. For the purposes of this section, providers participating in clinical trials shall obtain a patient's informed consent for participation in the clinical trial in a manner that is consistent with current legal and ethical standards. Such document shall be available to the health insurer upon request.
VII. Health plans providing coverage under this section and the providers participating in those same clinical trials shall develop a mutually agreed upon process to share appropriate aggregate clinical and financial data on the progress and outcome of clinical trials subject to this section. Health plans and the providers participating in clinical trials shall establish reasonable requirements for communication with the member's primary care provider regarding the member's clinical data.
VIII. The provisions of this section shall not apply to a policy, plan, or contract paid for under the federal Medicare program nor the state children's health insurance program.

Source. 2000, 264:1, eff. Jan. 1, 2001.

Section 415:18-m

    415:18-m Retroactive Denials Prohibited; Exceptions. –
I. In this section, "retroactive denial of a previously paid claim" means any attempt by an insurer to retroactively collect payments already made to a health care provider with respect to a claim by requiring repayment of such payments, reducing other payments currently owed to the provider, withholding or setting off against future payments, reducing or affecting the future claim payments to the provider in any other manner.
II. No insurer shall impose on any health care provider any retroactive denial of a previously paid claim or any part thereof unless:
(a) The insurer has provided the reason for the retroactive denial in writing to the health care provider; and
(b) The time which has elapsed since the date of payment of the challenged claim does not exceed 18 months. The retroactive denial of a previously paid claim may be permitted beyond 18 months from the date of payment only for the following reasons:
(1) The claim was submitted fraudulently;
(2) The claim payment was incorrect because the health care provider or the insured was already paid for the health care services identified in the claim;
(3) The health care services identified in the claim were not delivered by the health care provider;
(4) The claim payment was for services covered by Title XVIII, Title XIX, or Title XXI of the Social Security Act;
(5) The claim payment is the subject of an adjustment with a different insurer, administrator, or payor and such adjustment is not affected by a contractual relationship, association, or affiliation involving claims payment, processing, or pricing; or
(6) The claim payment is the subject of legal action.
III. An insurer shall notify a health care provider at least 15 days in advance of the imposition of any retroactive denials of previously paid claims. The health care provider shall have 6 months from the date of notification under this paragraph to determine whether the insured has other appropriate insurance, which was in effect on the date of service. Notwithstanding the contractual terms between the insurer and provider, the insurer shall allow for the submission of a claim that was previously denied by another insurer due to the insured's transfer or termination of coverage.

Source. 2002, 143:2. 2006, 104:2, eff. Aug. 7, 2006.

Section 415:18-n

    415:18-n Coverage for Certain Prosthetic Devices. –
I. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, except for supplemental policies covering a specified disease or other limited benefit, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state and whose principal place of employment is in this state, coverage for benefits for prosthetic devices under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section.
II. In this section, "prosthetic device" means an artificial limb device to replace, in whole or in part, an arm or leg.
III. An insurer shall not impose any annual or lifetime dollar maximum on coverage for prosthetic devices other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy.
IV. An insurer shall not apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the policy other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy.
V. The provisions of this section shall apply to group health service plan contracts issued pursuant to RSA 420-A, and to health maintenance organization policies and plans issued pursuant to RSA 420-B.

Source. 2003, 216:1. 2010, 188:13, eff. Aug. 20, 2010.

Section 415:18-o

    415:18-o Group or Blanket Plan Prescription Drug Information Cards. –
I. Each insurer that issues or renews any policy of group accident or health insurance which provides coverage for prescription drugs or devices, or which contracts with an entity providing such prescription drug coverage, including but not limited to pharmacy benefit manager companies, shall issue to certificate holders a card or other technology containing uniform prescription drug information. The uniform prescription drug information card or technology shall include all of the fields required by the health insurance provider for claims processing in a clear, readable, and understandable manner on the card or other technology issued, shall include the information required under RSA 400-A:15-c, and shall include, at a minimum, the following information:
(a) The name or trademark logo of the insurer and, if another company administers the prescription benefit, the name or trademark logo of the benefit administrator.
(b) The certificate holder's name and identification number.
(c) All of the electronic transaction routing information required by the insurer or its benefit administrator in order for the pharmacy to electronically process a prescription claim, including but not limited to the BIN number labeled as such or the Processor Control Number labeled as such, or both.
II. All subscriber health insurance cards issued after January 1, 2004 shall contain the information required under paragraph I.
III. A new uniform prescription drug information card, as required under this section, shall be issued by an insurer upon enrollment of new members and when reissuing a new card to current members when there is a change in the certificate holder's pharmacy coverage that affects data contained on the card.

Source. 2003, 286:3. 2010, 188:13, eff. Aug. 20, 2010. 2016, 111:3, eff. Jan. 1, 2017.

Section 415:18-p

    415:18-p Third-Party Payment of Covered, Court-Ordered Services. –
The existence of a court order under RSA 169-B, RSA 169-C, or RSA 169-D for a service, program, or placement that is covered under any insurance for the minor shall not be considered in determining qualification for third-party payment under such insurance. Benefits for such services shall be subject to the same dollar limits, deductibles, co-payments and co-insurance factors and to the terms and conditions of the policy or certificate, including any managed care provisions. However, the claimant or claimant's representative shall have 48 hours from the commencement of a court-ordered service, placement, or program to seek any pre-authorization, pre-certification, or referral required under the terms of the policy. The determination of these preservice claims for court-ordered services for a minor shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 48 hours after receipt of the request and sufficient information, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the insurer shall notify the claimant or claimant's representative within 24 hours of receipt of the request and shall advise the claimant or claimant's representative of the specific information necessary to determine to what extent benefits are covered or payable. The claimant or claimant's representative shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Thereafter, notification of the claim determination shall be made as soon as possible, but in no case later than 48 hours after the earlier of:
I. The insurer's receipt of the specified additional information; or
II. The end of the period afforded the claimant or claimant's representative to provide the specified additional information.

Source. 2004, 117:1, eff. Aug. 15, 2004.

Section 415:18-q

    415:18-q Coverage for Certified Midwives. – Each insurer that issues or renews any policy of group accident or health insurance providing maternity benefits shall also provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage consistent with the terms and conditions of the policy for services rendered by a midwife certified under RSA 326-D. Such coverage shall be subject to each insurer's standards and mechanisms for credentialing and contracting pursuant to RSA 420-J:4 and RSA 420-J:8 respectively, where applicable, and contingent upon services being provided in a licensed health care facility or at home and within the scope of practice of a certified midwife. Benefits provided shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2006, 8:2. 2008, 298:2. 2010, 188:13, eff. Aug. 20, 2010.

Section 415:18-r

    415:18-r Coverage for the Cost of Testing for Bone Marrow Donation. –
I. Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state and who meet the criteria for testing as established by the Match Registry (the National Marrow Donor Program), coverage for laboratory fee expenses up to $150 arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for utilization in bone marrow transplantation. The testing shall be performed in a facility that is accredited by the American Association of Blood Banks or its successors, or the College of American Pathologists, or its successors, or any other national accrediting body with requirements that are substantially equivalent to or more stringent than those of the College of American Pathologists, and is licensed under the Clinical Laboratory Improvement Act of 1967, 42 U.S.C. section 263a, as amended. At the time of the new testing, the person tested shall complete and sign an informed consent form that also authorizes the results of the test to be used for participation in the National Marrow Donor Program and shall acknowledge a willingness to be a bone marrow donor if a suitable match is found.
II. In addition to paragraph I, the testing facility shall not bill, charge, collect a deposit from, seek payment or reimbursement from, or have recourse against a covered person or a person acting on behalf of the covered person for any portion of the laboratory fee expenses.

Source. 2006, 187:2. 2010, 188:13. 2011, 133:6, eff. Jan. 1, 2012.

Section 415:18-s

    415:18-s Coverage for Children's Early Intervention Services. – Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical, rehabilitation, or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for expenses arising from the services of licensed and credentialed occupational therapists, physical therapists, speech-language pathologists, and clinical social workers working with children from birth to 36 months of age with an identified developmental disability and/or delay as specified in rules adopted pursuant to RSA 171-A:18, IV as long as the providing therapist receives a referral from the child's primary care provider if applicable. The benefits in this section shall not be subject to deductibles, copayments, or coinsurance; provided that the benefits included in this section may have a cap of $3,200 per child per year not to exceed $9,600 by the child's third birthday. For a health care contract that meets the definition of a "high deductible plan" set forth in 26 U.S.C. section 223(c)(2) or a catastrophic health plan, as defined under the Patient Protection and Affordable Care Act of 2009, a carrier shall be exempt from the deductible provisions of this section and may apply a deductible to children's early intervention therapy services until an enrollee's deductible has been satisfied for the year. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall apply to the medical assistance program, pursuant to RSA 161 and RSA 167.

Source. 2007, 338:2. 2010, 188:13, eff. Aug. 20, 2010. 2020, 26:40, eff. Sept. 18, 2020. 2021, 56:9, eff. July 24, 2021.

Section 415:18-t

    415:18-t Coverage for Obesity and Morbid Obesity; Group. – Each insurer that issues or renews any policy of group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the diseases and ailments caused by obesity and morbid obesity and treatment for such, including bariatric surgery, when the prescribing physician has issued a written order stating that treatment is medically necessary and in accordance with the patient qualifications and treatment standards set forth by the American Society for Metabolic and Bariatric Surgery or the American College of Surgeons. Such treatment standards may include, but not be limited to, pre-operative psychological screening and counseling, behavior modification, weight loss, exercise regimens, nutritional counseling, and post-operative follow-up, overview, and counseling of dietary, exercise, and lifestyle changes. The covered insured shall be at least 18 years of age. The benefits included in this section shall be subject to the terms and conditions of the policy and shall be no less extensive than coverage provided for similar conditions or illnesses.

Source. 2008, 389:2. 2010, 188:13, eff. Aug. 20, 2010.

Section 415:18-u

    415:18-u Coverage for Hearing Aids. –
Each insurer that issues or renews any policy or certificate for delivery in this state of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide coverage for the professional services associated with the practice of fitting, dispensing, servicing, or sale of hearing instruments or hearing aids by a hearing instrument dispenser or other hearing care professional. The benefits included in this section shall not be subject to any greater deductible or coinsurance or copay than any other benefits provided by the insurer. Insurers are required to cover the cost of a hearing aid for each ear, as needed, as well as related services necessary to assess, select, and fit the hearing aid with a maximum for the hearing aid and related services of no less than $1,500 per hearing aid every 60 months. The insured may choose a higher price hearing aid and pay the difference in cost. The hearing aid shall be prescribed and dispensed by a licensed audiologist or hearing instrument specialist. Notwithstanding any provision of law or rule to the contrary, the coverage under this section shall not apply to the medical assistance program, pursuant to RSA 161 and RSA 167. In this section:
I. "Hearing care professional" means a person who is a licensed audiologist, a licensed hearing instrument dispenser, or a licensed physician.
II. "Hearing instrument" or "hearing aid" means any instrument or device designed, intended, or offered for the purpose of improving a person's hearing and any parts, attachments, or accessories, including earmolds. Batteries, cords, and individual or group auditory training devices and any instrument or device used by a public utility in providing telephone or other communication services are excluded.
III. "Hearing instrument dispenser" means a person who is a hearing care professional that engages in the selling, practice of fitting, selecting, recommending, dispensing, or servicing of hearing instruments or the testing for means of hearing instrument selection or who advertises or displays a sign or represents himself or herself as a person who practices the testing, fitting, selecting, servicing, dispensing, or selling of hearing instruments.
IV. "Practice of fitting, dispensing, servicing, or sale of hearing instruments" means the measurement of human hearing with an audiometer, calibrated to the current American National Standard Institute standards, for the purpose of making selections, recommendations, adoptions, services, or sales of hearing instruments including the making of earmolds as a part of the hearing instrument.

Source. 2010, 362:2, eff. Jan. 1, 2011.

Section 415:18-v

    415:18-v Reimbursement for Ambulance Service Providers. – Each insurer that issues or renews any policy of group or blanket accident or health insurance that constitutes health coverage under RSA 420-G:2, IX, and that provides benefits for medically necessary ambulance services shall reimburse the ambulance service provider directly or by a check payable to the insured and the ambulance service provider subject to the terms and conditions of the policy, plan, or contract. Nothing in this section shall preclude an insurer from negotiating with and subsequently entering into a contract with a non-participating ambulance provider that establishes rates of reimbursement for emergency medical services.

Source. 2011, 133:2, eff. Jan. 1, 2012.

Section 415:18-w

    415:18-w Naturopathy Providers; Payment for Equivalent Types of Services; Group. – Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses may provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for expenses arising from a health service performed by a doctor of naturopathic medicine licensed under RSA 328-E if that particular type of service is within the scope of practice of such doctor and if the insurer would reimburse for that type of service when performed by any other type of health care provider. Such coverage, if provided, shall be subject to each insurer's standards and mechanisms for determining medical necessity, for credentialing pursuant to RSA 420-J:4, and for contracting pursuant to RSA 420-J:8. Any such benefits provided shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2012, 278:2, eff. Jan. 1, 2013.

Section 415:18-x

    415:18-x Repealed by 2014, 299:8, II, eff. Oct. 1, 2017. –

Section 415:18-y

    415:18-y Oral Anti-Cancer Therapies. –
I. No insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for anti-cancer medications that are injected or intravenously administered by a health care provider and patient administered anti-cancer medications, including but not limited to those orally administered or self-injected, shall require a higher copayment, deductible, or coinsurance amount for patient administered anti-cancer medication than it requires for injected or intravenously administered anti-cancer medications, regardless of the formulation or benefit category determination by the policy or plan.
II. An insurer shall not comply with paragraph I by:
(a) Increasing the copayment, deductible, or coinsurance amount required for injected or intravenously administered anti-cancer medication that are covered under the policy or plan.
(b) Reclassifying benefits with respect to anti-cancer medications.
III. In this section, "anti-cancer medication" means drugs and biologics that are used to kill, slow, or prevent the growth of cancerous cells.
IV. If the cost-sharing requirements for orally administered anti-cancer medications do not exceed $200 per prescription fill, the health plan shall be deemed in compliance with this section.
V. For a health care contract that meets the definition of a "high deductible plan" set forth in 26 U.S.C. section 223(c)(2), a carrier shall be exempt from the provisions of paragraphs I-IV until an enrollee's deductible has been satisfied for the year.
VI. This section shall apply only to oral anti-cancer medications where an intravenously administered or injected anti-cancer medication is not medically appropriate.
VII. This section shall not apply to policies which are solely to replace income or pay a predetermined fixed amount based on the occurrence of a specified medical or health event.

Source. 2015, 263:7, eff. Jan. 1, 2017.

Section 415:18-z

    415:18-z Coverage for Early Refills of Prescription Eye Drops. –
I. Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for one early refill of a prescription for eye drops if the following criteria are met:
(a) For prescription eye drops dispensed as a 30-day supply, the enrollee requests the refill no earlier than 21 days after the later of the following dates:
(1) The date the original prescription was dispensed to the enrollee; or
(2) The date that the most recent refill of the prescription was dispensed to the enrollee;
(b) For prescription eye drops dispensed as a 90-day supply, the enrollee requests the refill no earlier than 63 days after the later of the following dates:
(1) The date the original prescription was dispensed to the enrollee; or
(2) The date that the most recent refill of the prescription was dispensed to the enrollee;
(c) The prescribing health care provider indicated on the original prescription that a specific number of refills are authorized;
(d) The refill requested by the enrollee does not exceed the number of refills indicated on the original prescription;
(e) The prescription has not been refilled more than once during the 30-day or 90-day period prior to the request for an early refill; and
(f) The prescription eye drops are a covered benefit under the enrollee's health plan.
II. Benefits provided under this section shall not be subject to any greater copayment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2016, 326:2, eff. Aug. 23, 2016.

Section 415:18-aa

    415:18-aa Coverage for Blood Lead Testing. – Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses shall provide to each group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the costs of blood lead testing conducted pursuant to RSA 130-A:5-a. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2018, 4:12, eff. Feb. 8, 2018.

Section 415:18-bb

    415:18-bb Coverage for Medically Necessary Dental Services. – Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for medically necessary dental services resulting from an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Treatment made necessary due to injury to the jaw and oral structures other than teeth shall be covered without time limit. Coverage under this section shall be subject to such other terms and conditions of the policy that may apply.

Source. 2019, 113:2, eff. Aug. 20, 2019.

Section 415:18-cc

    415:18-cc Coverage for Perfluoroalkyls (PFAS) and Perfluorinated Compounds (PFCS) Blood Testing. – Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for coverage for perfluoroalkyls (PFAS) and perfluorinated compounds (PFCS) blood testing. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer.

Source. 2020, 30:10, eff. Sept. 21, 2020.

Section 415:18-dd

    415:18-dd Coverage for Epinephrine Auto-Injectors. – Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for the cost of epinephrine auto-injectors. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer and shall be subject to the terms and conditions of the policy. In this section, "epinephrine auto-injector" means a single-use device used for the automatic injection of a pre-measured dosage of epinephrine into the human body.

Source. 2020, 13:10, eff. Jan. 1, 2021.

Section 415:18-ee

    415:18-ee Coverage for Long-Term Antibiotic Therapy Tick-Borne Illness. – Each insurer that issues or renews any policy of group or blanket accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for long-term antibiotic therapy for tick-borne illness when determined to be medically necessary and ordered by a licensed infectious disease physician after making a thorough evaluation of the patient's symptoms, diagnostic test results or response to treatment. Benefits provided under this section shall not be subject to any greater co-payment, deductible, or coinsurance than any other similar benefits provided by the insurer. In this section, "long-term antibiotic therapy" means the administration of oral, intramuscular, or intravenous antibiotics singly or in combination, for periods of time in excess of 4 weeks.

Source. 2020, 39:21, eff. June 30, 2021.

Section 415:19

    415:19 Policies Under Franchise Plan. – RSA 415:15 shall not be construed to prohibit the issuance or delivery in this state of policies under the franchise plan herein defined provided the rates charged, benefits payable, or underwriting procedure used do not discriminate between franchise plans. Accident and health insurance on a franchise plan is hereby declared to be that form of accident and health insurance issued to (1) 3 or more employees of any corporation, copartnership, or individual employer or any governmental corporation, agency or department thereof; or (2) 10 or more members of any trade or professional association or of a labor union or of any other association having had an active existence for at least 2 years where such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance; where such persons, with or without their dependents, are issued the same form of an individual policy varying only as to amounts and kinds of coverage applied for by such persons, under an arrangement whereby the premiums on such policies may be paid to the insurer periodically by the employer, with or without payroll deductions, or by the association for its members.

Source. 1947, 162:4. RSA 415:19. 1973, 74:1, eff. April 9, 1973.

Section 415:19-a

    415:19-a Student Insurance Policies. –
Student major medical expense coverage is hereby declared to be that form of accident and health insurance issued as large group coverage to enrolled students at an accredited college, university, or other educational institution. No coverage other than student major medical expense coverage shall be issued as student large group coverage. Student major medical expense plan coverage shall:
I. Provide the same form of major medical expense coverage under an arrangement whereby the premiums for such policies are paid to the insurer by the college, the university, or other educational institution.
II. Not include a pre-existing condition exclusion period.
III. Be considered large group coverage, subject to all applicable laws and rules that generally apply to large group accident and health insurance coverage, except those set forth in RSA 420-G and RSA 415:18, VII, VII-a, VII-b, XVI, and XVII.

Source. 2010, 188:2, eff. Aug. 20, 2010.

Section 415:19-b

    415:19-b Debt-Related Mortgage Disability and Mortgage Accidental Death Insurance. –
A group of individuals may be insured under a mortgage disability or mortgage accidental death policy issued to a creditor, or to the trustee of a creditor, which creditor or trustee shall be deemed the policyholder, to insure debtors of the creditor or creditors, subject to the following requirements:
I. The debtors eligible for insurance under the policy shall be all the debtors of the creditor or creditors whose indebtedness is repayable in installments, or all of any class or classes thereof determined by conditions pertaining to the indebtedness or to the purchase giving rise to the indebtedness. The policy may provide that the term "debtors" shall include the debtors of one or more subsidiary corporations, and the debtors of one or more affiliated corporations, proprietors, or partnerships if the business of the policyholder and of such affiliated corporations, proprietors, or partnerships is under common control through stock ownership, contract, or otherwise.
II. The premium for the policy shall be paid by the policyholder, either from the creditor or creditor's funds, or from charges collected from the insured debtors, or from both.
III. The amount of indemnity payable with respect to any debtor shall at no time exceed the amount owed by the debtor which is repayable in installments to the debtor's creditor.
IV. The insurance shall be payable to the policyholder. Such payment shall reduce or extinguish the unpaid indebtedness of the debtor to the extent of such payment.
V. All the provisions of RSA 417, and specifically RSA 417:4, XVI, shall apply to any policy issued under this section.

Source. 2012, 103:1, eff. July 28, 2012.

Section 415:19-c

    415:19-c Credit Union Accidental Death and Dismemberment Insurance. – A group of individuals who are members of a credit union may be insured under an accidental death and dismemberment policy issued to that credit union, which shall be deemed the policyholder.

Source. 2014, 19:1, eff. July 22, 2014.

Section 415:20

    415:20 Penalty. –
Any insurer, agent, broker or any person, firm, association or corporation that violates any provision of this chapter or any rule issued pursuant to it, or any relevant provision of RSA 161-H, may at the discretion of the commissioner be subject to paragraph I or II, or both.
I. Its certificate of authority may be indefinitely suspended or revoked.
II. A civil fine not to exceed $2,500 may be imposed for each violation. Repeated violations of the same provision or regulation shall constitute separate civil offenses.

Source. 1913, 226:13. PL 281:27. RL 331:28. RSA 415:20. 1975, 494:4. 1994, 214:5, eff. Oct. 1, 1994.

Section 415:21

    415:21 Health Insurance Through Joint Action. –
I. Notwithstanding any contrary provision of this chapter or of any other law, 2 or more insurance companies authorized to carry on the business of health insurance in this state may join together to offer to any resident of this state who has reached or passed his sixty-fifth birthday and to the spouse of such resident, insurance against major financial loss from accident or disease. Such insurance may be offered by such companies in their own names or in the name of a voluntary unincorporated association or other organization formed by such companies solely for the purpose of offering this type of insurance. The forms of applications, certificates and policies of such insurance and the applicable premium rates shall be filed with the insurance commissioner and shall conform to the requirements of this chapter as to forms of policies of accident and sickness insurance so far as practical and applicable and the commissioner may require such additional pertinent information as he may deem necessary and require deviation from the statutory provisions for the forms of such policies.
II. The joint action authorized by this section may be taken in connection with a plan to offer such insurance to residents of other states in combination with insurance offered to residents of this state subject to approval by the insurance commissioner.
III. A financial summary concerning any insurance written under the authority of this section shall be furnished annually to the insurance commissioner in such form as he may prescribe. If the insurance commissioner finds that any forms for such insurance are not in the public interest or that the premium rates charged are by reasonable assumptions excessive in relation to the benefits provided, he may disapprove such forms or premium rates after notice of at least 20 days and hearing. Any person aggrieved by any order or decision of the insurance commissioner under this section shall be entitled to a rehearing and appeal in accordance with the provisions of RSA 541.

Source. 1963, 295:1, eff. Sept. 1, 1963.

Section 415:22

    415:22 Newborn Children. –
I. All individual and group health insurance policies providing coverage on a provision of service or an expense incurred basis shall also provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber or a newly born child of a dependent child of the insured or subscriber from the moment of birth.
II. Coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
III. If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child and payment of the required premium or fee must be furnished to the insurer or nonprofit service or indemnity corporation within 31 days after the date of birth in order to have the coverage continue beyond such 31-day period. Unless the policy or contract specifically provides that grandchildren of the insured or subscriber are eligible for coverage, coverage for newly born children of a dependent child of the insured or subscriber shall not continue beyond the initial 31-day period following birth. Nor shall such newly born children be considered dependents of the insured for any purpose addressed in this title.
IV. This section applies to all insurance policies and subscriber contracts delivered or issued for delivery in this state including those in force as of July 5, 1975.

Source. 1975, 110:1. 1994, 166:7. 1996, 188:5, 6. 1997, 190:8, eff. Jan. 1, 1998.

Section 415:22-a

    415:22-a Coverage During Adoption Proceedings. – All individual and group health insurance policies which provide coverage for a family member of the insured shall, as to such family member's coverage, also provide that health insurance benefits applicable for children are payable with respect to any minor from the date such minor is placed in the custody of the insured pursuant to an adoption proceeding under the provisions of RSA 170-B. Such health insurance benefits shall terminate upon dismissal or withdrawal of the petition for adoption.

Source. 1992, 222:7, eff. Jan. 1, 1993.

Section 415:22-b

    415:22-b Notification of Allowable Benefit. – All individual and group health insurers providing benefits for medical and hospital expenses shall provide to each certificate holder, on request, a written statement of the dollar amount of allowable benefit for any procedure which is requested by the appropriate procedure code.

Source. 1993, 102:1, eff. Jan. 1, 1994.

Section 415:23

    415:23 Jurisdiction Over Certain Health Insurers. –
I. Notwithstanding any other provision of law, and except as provided in this section, any person or other entity which provides coverage in this state for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital, or optometric expenses, whether such coverage is by direct payment, reimbursement, or otherwise, shall be presumed to be subject to the jurisdiction of the department unless the person or other entity shows that, while providing such services, it is subject to the jurisdiction of another agency of this or another state or of the federal government. The provisions of this section shall not apply to dental service corporations established by 1961, 345 or vision service corporations established by 1969, 614.
II. A person or entity may show that it is subject to the jurisdiction of another agency or department of this or another state or of the federal government by providing to the commissioner the appropriate certificate or license issued by the other governmental agency which permits or qualifies it to provide those services for which it is licensed or certificated.
III. Any person or entity which is unable to show that it is subject to the jurisdiction of another agency of this or another state or of the federal government shall submit to an examination by the commissioner to determine the organization and solvency of the person or the entity and to determine whether or not such person or entity is in compliance with the applicable provisions of Title XXXVII.
IV. Any person or entity unable to show that it is subject to the jurisdiction of another agency of this or another state or of the federal government shall be subject to all appropriate provisions of Title XXXVII regarding the conduct of its business.
V. The department shall prepare and maintain for public inspection a list of those persons or entities described in paragraph I which it knows to be operating in this state. There shall be no liability of any kind on the part of the state, the department, and its employees for the accuracy of such list or for any comments made with respect to it.
VI. Any production agency or administrator licensed by the department which advertises, sells, transacts, or administers coverage in this state described in paragraph I which is provided by any person or entity described in paragraph III shall, if that coverage is not fully insured or otherwise fully covered by an admitted life or disability insurer, nonprofit hospital service plan, or nonprofit health care plan, advise in writing, any purchaser, prospective purchaser, and covered person of such lack of insurance or other coverage and shall advise, in writing, the attending lack of guaranty association protection.
VII. Any administrator licensed by the department which advertises or administers coverage in this state, described in paragraph I, which is provided by any person or entity described in paragraph III, shall advise any production agency licensed by the department of the elements of the coverage including the amount of "stop-loss" insurance in effect.
VIII. Nothing in this section shall relieve any person of any liability, civil or criminal, arising from any other statute or rule of this state or of any other governmental unit.

Source. 1983, 342:1, eff. Aug. 17, 1983.

Section 415:24

    415:24 Rate Modifications for Accident and Health Insurance Policies. –
I. Rate modifications on individual accident and health policy forms shall be filed with the commissioner prior to implementation.
II. At the time of filing new premium rates on any previously approved individual accident and health insurance policy form, other than forms for Medicare supplement policies and long-term care policies, the benefits provided by the policy form shall be deemed reasonable to the premium charge and the rates deemed approved, so long as the insurer complies with the terms of a loss ratio guarantee filed with the commissioner. The loss ratio guarantee agreement shall be in writing and shall include at least the following:
(a) A recitation of the anticipated annual and lifetime loss ratio standards included in the original actuarial memorandum filed with the policy form at the time of the initial approval of the policy form.
(b) A guarantee that the actual loss ratios in this state for the experience period in which the rates take effect, and for each experience period thereafter, will meet or exceed the anticipated annual loss ratio standards as recited in accordance with RSA 415:24, II(a). If the annual earned premium volume in this state under a policy form is less than $1,000,000, the loss ratio guarantee shall be based on the actual nationwide loss ratio for the policy form. If the annual earned premium volume nationwide is less than $1,000,000, the experience period shall be extended until the end of the calendar year in which $1,000,000 of earned premiums is attained.
(c) A guarantee that the actual loss ratio results for each calendar year the rates are in effect shall be independently audited during the second quarter of the following year at the expense of the insurer. The audited results shall be reported to the commissioner no later than the date for filing the applicable accident and health policy experience exhibit. The audit shall be conducted in accordance with generally accepted auditing or actuarial standards and shall be signed by a certified public accountant or a member of the American Academy of Actuaries.
(d) A guarantee that affected policyholders in this state shall be issued a proportional refund of premiums paid in the amount necessary to bring the actual loss ratio up to the anticipated annual loss ratio standards as recited in accordance with RSA 415:24, II(a). If national loss ratios are used, the total amount refunded in this state shall equal the dollar amount necessary to achieve the loss ratio standards, multiplied by the total premium earned in this state on the policy form and divided by the total premiums earned in all states on the policy form. The refund shall be made to all policyholders insured under the applicable policy form as of the last day of the experience period at issue and whose individual refund would equal $5 or more. The refund shall include interest at the then current accident and health reserve interest rate established by the National Association of Insurance Commissioners calculated from the last day of the experience period at issue until the date of payment, which shall be during the third quarter of the following year.
(e) A guarantee that refunds of less than $5 shall be aggregated by the insurer and paid to the department of insurance.
(f) A guarantee that no increase in premium rate obtained pursuant to this section will be implemented on any individual policy in this state until after the policyholder has received at least 30 days advance notice of the planned increase.
(g) For the purposes of this section, "loss ratio" means the ratio of incurred claims to earned premium by number of years of policy duration, for all combined durations.
(h) The commissioner shall adopt rules under RSA 541-A necessary for the proper administration of this section.

Source. 1992, 272:1, eff. Jan. 1, 1993.

Section 415:25

    415:25 Repealed by 2014, 3:12, VII, eff. Dec. 31, 2018. –

Section 415:26

    415:26 Price of Filling Prescriptions. –
I. A pharmacy benefits manager or insurer shall require a contracted pharmacy to charge an enrollee or insured person the pharmacy's usual and customary price of filling the prescription or the contracted copayment, whichever is less.
II. Once it has settled a claim for filling a prescription for an enrollee or insured person and notified the pharmacy of the amount the pharmacy benefits manager or insurer shall pay to the pharmacy for that prescription, the pharmacy benefits manager or insurer shall not lower the amount to be paid to the pharmacy by the pharmacy benefits manager or the insurer for such settled claim; provided, however, that this paragraph shall not apply if the claim was submitted fraudulently or with inaccurate or misrepresented information.
III. The commissioner shall adopt rules under RSA 541-A to implement this paragraph. Such rules shall include procedures for addressing complaints, provisions for enforcement, the receipt of complaints referred to the insurance department under RSA 318:47-h, III(b), and for reporting to the board of pharmacy on the status of complaints referred.

Source. 2016, 221:7, eff. June 9, 2016.

Section 415:27

    415:27 Medication Synchronization. –
I. An individual or group health insurance plan or policy providing prescription drug coverage in New Hampshire, shall permit and apply a prorated, daily cost-sharing rate to covered prescriptions for a chronic condition that are dispensed by an in-network pharmacy for less than a 30-day supply if the prescriber and pharmacist determine the fill or refill to be in the best interest of the patient for the management or treatment of a chronic, long-term care condition and the patient requests or agrees to less than a 30-day supply for the purpose of synchronizing the patient's medications. For the purposes of this paragraph, the insured's or enrollee's maintenance prescription drugs to be synchronized shall meet all of the following requirements:
(a) They are covered by the policy, certificate, or contract described in this chapter.
(b) They are used for the management and treatment of a chronic, long-term care condition and have authorized refills that remain available to the insured or enrollee.
(c) Except as otherwise provided in this paragraph, they are not a controlled substance included in schedules II-V.
(d) They meet all utilization management requirements specific to the maintenance-prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple, maintenance-prescription drugs.
(e) They are of a formulation that can be effectively split over required short-fill periods to achieve synchronization.
(f) They do not have quantity limits or dose-optimization criteria or requirements that will be violated when synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.
II. The plan or policy described in paragraph I shall apply a prorated, daily cost-sharing rate for maintenance-prescription drugs that are dispensed by an in-network pharmacy for the purpose of synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.
III. The plan or policy described in paragraph I shall not reimburse or pay any dispensing fee that is prorated. The insurer shall only pay or reimburse a dispensing fee that is based on each maintenance-prescription drug dispensed.
IV. A synchronization shall only occur once per year per maintenance-prescription drug.

Source. 2018, 103:1, eff. Jan. 1, 2019.