TITLE XXXVII
INSURANCE

Chapter 420-G
PORTABILITY, AVAILABILITY, AND RENEWABILITY OF HEALTH COVERAGE

Section 420-G:1

    420-G:1 Purpose. –
The purpose of this chapter is to:
I. Facilitate the portability, availability, and renewability of health coverage for all New Hampshire residents and persons principally employed in New Hampshire who wish to obtain health coverage or maintain it as individuals or as employees of large and small employers.
II. To promote competition among health carriers on the basis of efficient claims handling, ability to manage health care services, consumer satisfaction, and low administrative costs.
III. To regulate underwriting and rating practices in the small employer and individual markets so as to promote access to affordable coverage for higher risk groups or individuals.

Source. 1997, 344:1. 1998, 340:7. 2001, 295:1, eff. July 1, 2002.

Section 420-G:2


[Introductory paragraph of paragraph XV effective until 60 days after certification by the insurance commissioner that 29 C.F.R. section 2510.3-5(b) is valid and that issues raised in State of New York v. United States Department of Labor have been resolved, but not later than December 1, 2021; see also introductory paragraph of paragraph XV set out below.]
    420-G:2 Definitions. –
In this chapter:
I. "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer health carrier is in compliance with the provisions of and the rules adopted by the commissioner, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer health carrier in establishing premium rates for applicable health benefit plans.
I-a. "Case characteristics" means demographic or other relevant characteristics of a small employer group that may be considered by the health carrier in the determination of premium rates for that group.
II. "Commissioner" means the commissioner of insurance.
II-a. "Composite billing" means a method of calculating premium rates for small employer groups in which each enrolled employee's rate varies only by the enrolled employee's family composition.
III. "Creditable coverage" means any public or private health insurance or health benefit plan, whether insured or self-insured, unless that coverage consists solely of benefits excluded from the definitions of "health coverage" in paragraph IX or "individual health coverage" in paragraph XI. Notwithstanding the exclusion in paragraph IX, short-term, nonrenewable individual policies for medical, hospital, or major medical coverage issued pursuant to RSA 415:5, III or other law shall be considered "creditable coverage."
III-a. "Date of enrollment" means the first day of coverage under the plan, or, if there is a waiting period, the first day of the waiting period, which is typically the first day of work.
IV. "Department" means the department of insurance.
V. "Eligible dependents" means those persons who may be included under a covered person's health coverage by the terms of the policy or plan and in accordance with this chapter.
VI. "Eligible employee" means an employee who meets the requirements for eligibility set forth by the employer, the health coverage plan and state law.
VI-a. "Employee" means "employee" as defined in the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(6).
VI-b. "Essential health benefits" means the categories of coverage identified in 42 U.S.C. section 18022(b)(1) and as further defined and implemented by the Secretary of the Department of Health and Human Services from time to time.
VII. "Exclusion period" means the length of time that must expire before a health carrier will cover medical treatment expense relating to a preexisting condition.
VII-a. "Family composition" means health plan membership type, including: enrollee only; enrollee and spouse; enrollee and children; enrollee, spouse, and children; and other similar membership types.
VIII. "Health carrier" means any entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to provide, deliver, arrange for, pay for or reimburse any of the costs of health services; including an insurance company, a health maintenance organization, a nonprofit health services corporation, or any other entity providing health coverage.
IX. "Health coverage" means any hospital or medical expense incurred policy or certificate, nonprofit health services corporation subscriber contract, or health maintenance organization subscriber contract and any other health insurance plan or health benefit plan. For the purposes of this chapter, health coverage does not include:
(a) Accident-only or disability income insurance.
(b) Coverage issued as a supplement to liability insurance.
(c) Liability insurance, including general liability insurance and automobile liability insurance.
(d) Workers' compensation or similar insurance.
(e) Automobile medical-payment insurance.
(f) Credit only insurance.
(g) Coverage for on-site medical clinics.
(h) Short-term, individual, nonrenewable medical, hospital, or major medical policies.
(i) Other similar insurance coverage, specified in rules, under which benefits for medical care are secondary or incidental to other insurance benefits.
(j) If offered separately:
(1) Limited scope dental or vision benefits.
(2) Long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(3) Prescription drug benefits.
(4) Other similar, limited benefits as are specified in rules.
(k) If offered as independent, noncoordinated benefits:
(1) Specified disease or illness benefits.
(2) Hospital or surgical indemnity benefits.
(l) If offered as a separate insurance policy, Medicare supplemental health insurance, coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code, and similar supplemental coverage as specified in regulations.
IX-a. "Health coverage plan rate" means a rate that is uniquely determined for each of the coverages or health benefit plans a health carrier writes and that is derived from the market rate through the application of plan factors that reflect actuarially demonstrated differences in expected utilization and health care costs attributable to differences in the coverage design and/or the provider contracts that support the coverage and by including provisions for administrative costs and loads. The health coverage plan rate is periodically adjusted to reflect expected changes in the market rate, utilization, health care costs, administrative costs, and loads.
X. "Individual" means a person who is not eligible for health coverage through employment and that person's dependents.
XI. "Individual health coverage" means health coverage issued by a health carrier directly to an individual and not on a group or group remittance basis. For the purposes of this chapter, franchise insurance, as defined in RSA 415:19, shall be considered individual health coverage.
XII. (a) "Large employer" means an employer that employed on average at least 51 persons, on business days, during the previous calendar year.
(b) In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.
XII-a. "List billing" means a method of calculating premium rates for small employer groups in which each enrolled employee's rate varies only by the enrolled employee's attained age and the enrolled employee's family composition.
XII-aa. "Loss information" means the aggregate claims experience and shall include, but not be limited to, the number of covered lives, the amount of premium received, the amount of total claims paid, and the claims loss ratio. "Loss information" shall not include any information or data pertaining to the medical diagnosis, treatment, or health status that identifies an individual covered under the group contract or policy. Catastrophic claim information shall be provided as long as the provision of this information would not compromise any covered individual's privacy.
XII-b. "Loss ratio" means the ratio between the amount of premium received and the amount of claims paid by the health carrier under the group insurance contract or policy.
XII-c. "Market rate" means a single rate reflecting the carrier's average cost of actual or anticipated claims for all health coverages or health benefit plans the carrier writes and maintains in a market, including the nongroup individual health insurance market and, separately, the small employer group health insurance market, and which is periodically adjusted by the carrier to reflect changes in actual or anticipated claims.
XIII. "Medical underwriting" means the use of health status related information to establish or modify health coverage premium rates.
XIII-a. "Modified experience rating" means a rating methodology to apply only to individual policies sold in the nongroup market, which modifies community rating to allow for limited consideration of health status, as detailed in RSA 420-G:4, I(a).
XIV. "Preexisting condition" means a condition, whether physical or mental, for which medical advice, diagnosis, care or treatment was recommended or received during the 3 months immediately preceding the enrollment date of health coverage.
XIV-a. [Repealed.]
XIV-b. "Premium rate" means the rates used by a carrier to calculate the premium. For group coverage, premium rates shall be expressed as a rate per enrolled employee.
XV. "Qualified association trust or other entity" means an association established trust or other entity in existence on January 1, 1995, and providing health coverage within the state of New Hampshire to at least 1,000 employees and/or the dependents of association members, which association:
XV. "Qualified association trust or other entity" means an association established trust or other entity in existence on January 1, 1995, and providing health coverage within the state of New Hampshire to at least 250 employees and/or the dependents of association members, which association:
(a) Was established and maintained for a primary purpose other than the provision of health coverage;
(b) Was in existence for at least 10 years prior to January 1, 1995; and
(c) Conducts regular meetings within the state of New Hampshire designed to further the interests of its members, and all members shall be given notice of such meetings at least 30 days prior to the date of any meeting.
XV-a. "Rating period" means the time period for which the premium rate charged by a health carrier to an individual or a small employer for a health benefit plan is in effect.

[Paragraph XVI(a) effective until 60 days after certification by the insurance commissioner that 29 C.F.R. section 2510.3-5(b) is valid and that issues raised in State of New York v. United States Department of Labor have been resolved, but not later than December 1, 2021; see also paragraph XVI(a) set out below.]


XVI. (a) "Small employer" means a business or organization which employed on average, one and up to 50 employees on business days during the previous calendar year. A small employer is subject to this chapter whether or not it becomes part of an association, multi-employer plan, trust, or any other entity cited in RSA 420-G:3 provided it meets this definition.

[Paragraph XVI(a) effective 60 days after certification by the insurance commissioner that 29 C.F.R. section 2510.3-5(b) is valid and that issues raised in State of New York v. United States Department of Labor have been resolved, but not later than December 1, 2021; see also paragraph XVI(a) set out below.]


XVI. (a) "Small employer" means a business or organization which employed on average, one and up to 50 employees on business days during the previous calendar year. A small employer is subject to this chapter whether or not it becomes part of an association, multi-employer plan, trust, or any other entity cited in RSA 420-G:3 provided it meets this definition. However, with respect to coverage written under RSA 415-E to a bona fide pathway II association, whether self funded or fully insured, if such association has at least 250 New Hampshire covered lives and meets all applicable standards under RSA 415-E and all large group standards under this chapter, coverage offered by such association may be offered to sole proprietors or self-employed persons.
(b) In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.
XVII. "Waiting period" means a period of time, determined by the employer, which must expire before an employee is eligible for health coverage as a condition of employment.

Source. 1997, 344:1. 1998, 340:8; 375:1. 2000, 2:1. 2001, 120:1. 2003, 188:1-4. 2005, 225:1-8; 248:14. 2007, 289:21, 22. 2010, 346:3, I, eff. July 20, 2010. 2019, 220:1, 2, eff. Sept. 10, 2019; 346:409, 412.

Section 420-G:3

    420-G:3 Applicability and Scope of Chapter. –
I. This chapter shall apply to any entity licensed, controlled or regulated by RSA 415, RSA 415-E, RSA 420-A, RSA 420-B, or RSA 420-C which offers or provides health coverage for delivery in this state. This chapter shall also apply to any multi-employer plan, trust, association, claims administrator, claims paying agent or any other entity whether fully insured, partially insured, or self-funded which offers or provides health coverage for delivery in this state.
(a) This chapter shall not apply to pooled risk management programs which meet the standards established by RSA 5-B.
(b) This chapter shall not apply to student major medical expense coverage, except student major medical expense coverage shall be given credit and shall count as credit for previous health coverage as defined in RSA 420-G:7.
(c) Notwithstanding any other provision of this chapter, any multiple employer welfare arrangement which meets the requirements of RSA 415-E:2, III shall be exempt from the provisions of this chapter until January 1, 1998.
II. A qualified association trust or other entity, as defined by RSA 420-G:2, XV, shall comply with the requirements stated in RSA 420-G:10.
III. Notwithstanding any law to the contrary, the provisions of this chapter shall prevail with respect to the subject matter within this chapter.

Source. 1997, 344:1; 344:11. 2002, 207:10. 2010, 188:12, eff. Aug. 20, 2010. 2019, 220:13, eff. Sept. 10, 2019.

Section 420-G:4

    420-G:4 Premium Rates. –
I. Health carriers providing health coverage to individuals and small employers under this chapter shall be subject to the following:
(a) All premium rates charged shall be guaranteed for a rating period of at least 12 months, and shall not be changed for any reason, including but not limited to a change in the group's case characteristics.
(b) Market rate shall be established by each health carrier for all of its health coverages offered to individuals and, separately, for all of its health coverages offered to small employers.
(c) Health carriers shall calculate health coverage plan rates for each of the coverages or health benefit plans written by that carrier. Variations in health coverage plan rates shall be solely attributable to variations in expected utilization or cost due to differences in coverage design and/or the provider contracts or other provider costs associated with specific coverages and shall not reflect differences due to the nature of the groups or eligible persons assumed to select particular health coverages.
(d)(1) In establishing the premium charged, health carriers providing coverage to individuals and small employers shall vary the premium rate with respect to the particular plan or coverage involved only by:
(A) Whether the plan or coverage covers an individual or family;
(B) Geographic rating area, except that the state shall constitute a single geographic rating area;
(C) Age, except that the maximum premium differential for age as determined by ratio shall be 3 to 1 for adults; and
(D) Tobacco use, except that the maximum differential rate due to tobacco use shall be 1.5 to 1.
(2) With respect to family coverage under an individual or small group health insurance policy, the rating variations permitted under subparagraphs (1)(A) and (D) shall be applied based on the portion of the premium that is attributable to each family member covered under the plan.
(3) Carriers shall adjust each health coverage plan or premium rate for age, based on the portion of the premium that is attributable to each family member covered under the plan or certificate, using the uniform age rating factors established by the commissioner pursuant to RSA 420-G:14, I(a)(2).
(e) [Repealed.]
(f) Each rating factor that a carrier chooses to utilize in the individual market shall be reflective of claim cost variations that correlate with that factor independently of claim cost variations that correlate with any of the other allowable factors.
(g) The same rating methodology shall apply to newly covered individuals and to individuals renewing at each annual renewal date, or to new small employers and small employers renewing at each annual renewal date or anniversary date. Rating methodology shall not be construed to include health carrier incentives to individual subscribers or members to participate in wellness and fitness programs provided such incentives are approved by the insurance department.
(h) The commissioner shall not approve any filing if such filing is excessive, inadequate, or contrary to the intent of this chapter.
II. (a) Health carriers providing health coverage to large employers may not require any person, as a condition of receiving health coverage or continued health coverage, to pay a premium or contribution that is greater than that of similarly situated persons based on any health status related factor of that person or that person's dependents.
(b) Nothing in subparagraph (a) shall be construed to restrict the amount that a health carrier may charge a large employer, nor to prevent a health carrier from establishing premium discounts or rebates or modifying copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
III. [Repealed.]

Source. 1997, 344:1. 1998, 340:9, 10. 2001, 295:2; 296:1, 2. 2003, 188:5, 6, 15. 2005, 225:9, 10, 13, 15. 2013, 272:5, 6, eff. Jan. 1, 2014. 2019, 220:3, eff. Sept. 10, 2019.

Section 420-G:4-a

    420-G:4-a Repealed by 2016, 111:7, I, eff. June 19, 2016. –

Section 420-G:4-b

    420-G:4-b Repealed by 2016, 111:7, II, eff. June 19, 2016. –

Section 420-G:4-c

    420-G:4-c Health Coverage Tax Incentive Plan. –
I. Any carrier that offers small group health coverage in the state shall make its small employer group coverage available with a limited open enrollment period to individual employees of small employers when the coverage is purchased through a premium only cafeteria plan that satisfies the requirements of 26 U.S.C. section 125 and RSA 275:43-c.
II. [Repealed.]

Source. 2010, 204:2, eff. Aug. 21, 2010. 2019, 220:14, eff. Sept. 10, 2019.

Section 420-G:4-d

    420-G:4-d Essential Health Benefits. –
I. All health coverage offered by health carriers to individuals or small employers shall include coverage for essential health benefits and provide essential health benefits in a plan substantially equivalent to New Hampshire's essential health benefit benchmark plan in effect for the plan year 2019.
II. If the federal government ceases to define essential health benefits, the commissioner shall define essential health benefits for New Hampshire by rulemaking pursuant to RSA 541-A. The New Hampshire essential health benefits shall include at least the following general categories and the items and services covered within the categories:
(a) Ambulatory patient services.
(b) Emergency services.
(c) Hospitalization.
(d) Maternity and newborn care.
(e) Mental health and substance use disorder services, including behavioral health treatment.
(f) Prescription drugs.
(g) Rehabilitative and habilitative services and devices.
(h) Laboratory services.
(i) Preventive and wellness services and chronic disease management.
(j) Pediatric services, including oral and vision care; provided, that health coverage that does not specifically include such pediatric services shall be deemed to have offered the essential health benefit under this subparagraph if the health carrier has obtained reasonable assurance that such pediatric services are provided to the purchaser of the health coverage.
III. In defining the essential health benefits under paragraph II, the commissioner shall:
(a) Ensure that such essential health benefit reflects an appropriate balance among the categories described in such subparagraph, so that benefits are not unduly weighted toward any category;
(b) Not define essential health benefits in a manner which would allow carriers to make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;
(c) Consider the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;
(d) Ensure that health benefits established as essential are not subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life;
(e) Ensure that a health plan shall not be treated as providing coverage for the essential health benefits unless the plan provides that:
(1) Coverage for emergency department services shall be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the provision of services which is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and
(2) If such services are provided out-of-network, the cost-sharing requirement, such as a copayment amount or coinsurance rate is the same requirement which would apply if such services were provided in-network; and
(f) Ensure that the New Hampshire essential benefits are at least actuarially equivalent to the essential health benefits previously established by the federal government.
(g) Ensure essential health benefits are provided in a plan substantially equivalent to New Hampshire's essential health benefit benchmark plan in effect for plan year 2019.

Source. 2019, 220:4, eff. Sept. 10, 2019.

Section 420-G:5

    420-G:5 Medical Underwriting. –
I. Health carriers providing health coverage shall not perform medical underwriting, including the use of health statements or screenings or the use of prior claims history.
II. Regardless of claim experience, health status, or medical history, health carriers providing health coverage for individual or small employers shall not refuse to write or issue any of their available coverages or health benefit plans to any individual or small employer group that elects to be covered under that plan and agrees to make premium payments and meet the other requirements of the plan.
II-a. Health carriers shall not establish any annual or lifetime limits on the dollar value of essential health benefits for any individual, except annual or lifetime limits may be imposed on specific covered benefits that are not essential health benefits to the extent permitted under federal law as of January 1, 2019.
III. Health carriers providing health coverage for small employer groups shall not knowingly provide health coverage to groups where the employer has discriminated based on health status or claims history against any employee or potential employee or his or her dependents with respect to participation in an employer-sponsored health benefit plan.
IV. Health carriers shall not offer riders or endorsements to exclude certain illnesses or health conditions in order to avoid the purpose of this chapter.
V. Individual health insurance carriers shall be responsible for ascertaining the eligibility of any individual applicant or insured for high risk pool coverage. If a carrier determines that an individual meets any of the eligibility criteria set forth in RSA 404-G:5-e, the carrier shall give the individual written notice, with the declination of coverage, the coverage offering or upon a rate increase at renewal. The notice shall include information about available benefits and exclusions of high risk pool coverage and the name, address, and telephone number of the pool administrator or the administrator's designee.
VI. It shall constitute an unfair trade practice under RSA 417 for an insurer, insurance producer, or third party administrator to refer an individual employee to the pool, or arrange for an individual employee to apply to the pool, for the purpose of separating that employee from group health insurance coverage provided in connection with the employee's employment.
VII. Health carriers and health insurance producers shall ensure that persons seeking coverage through a small employer group who are required to complete a health statement have an option to convey the required information directly to the carrier or the producer through a secure means and bypassing the employer.
VIII. [Repealed.]

Source. 1997, 344:1. 1998, 340:11. 2001, 295:12. 2003, 188:7; 201:1, 2. 2004, 251:10, 11. 2005, 225:11. 2006, 125:1. 2009, 235:15. 2011, 189:7, eff. Aug. 13, 2011. 2019, 113:9, eff. Aug. 20, 2019; 220:5, eff. Sept. 10, 2019.

Section 420-G:6

    420-G:6 Guaranteed Issue and Renewability. –
I. Health carriers shall not establish rules of eligibility, including continued eligibility, for health coverage in relation to the following health status related factors of any employee or dependent:
(a) Health status.
(b) Medical condition, including both physical and mental illness.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions arising out of domestic violence.
(h) Disability.
II. Paragraph I shall not be construed to require health carriers to provide particular benefits under the terms of such health coverage, or to prevent health carriers from limiting or restricting the amount, level, extent or nature of the benefits for similarly situated persons under the health coverage. Paragraph I shall also not be construed to require health carriers to issue health coverage to an individual with existing health coverage, except where the individual indicates an intent to replace the existing health coverage.
II-a. [Repealed.]
III. Health carriers shall actively market, issue, and renew all of the health coverages they sell in the individual and small employer market to all individuals and small employers in that market. Health carriers offering health coverage to small employers shall permit small employers to purchase health coverage at any point during the year, with the small employer's health coverage consisting of the 12-month period beginning with the small employer's effective date of coverage.
III-a. A health carrier shall not rescind health coverage issued to an individual or with respect to an individual covered under health coverage issued to a small or large employer, including a group to which the individual belongs or family coverage in which the individual is included, after the individual is covered under the plan, unless:
(a) The individual, or a person seeking coverage on behalf of the individual, performs an act, practice, or omission that constitutes fraud; or
(b) The individual makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan or coverage.
III-b. For the purposes of subparagraph III-a(a), a person seeking coverage on behalf of an individual shall not include a producer, or an employee or authorized representative of the health carrier.
III-c. A health carrier in the individual, small group, or large group market shall provide individuals equal access to all health programs, coverage, or activities without discrimination on the basis of sex, sexual orientation, gender identity, race, creed, color, marital status, familial status, physical or mental disability, or national origin, as those terms are defined under RSA 354-A.
IV. [Repealed.]
V. Health coverages subject to this chapter shall be renewable to all individuals, regardless of age or eligibility for Medicare, or to employees and eligible dependents at the option of the small or large employer, except for the following reasons:
(a) Nonpayment of required premiums.
(b) Fraud or intentional misrepresentation on the part of an individual or an individual's representative, or on the part of an employer, employee, dependent, or an employee's representative.
(c) [Repealed.]
(d) Failure of an employer sponsoring group coverage to meet the minimum employee participation number or percentage requirement of the health coverage.
(e) The employer medically underwrites or otherwise violates a provision of this chapter.
(f) The health carrier is ceasing to offer health coverage in such market, in accordance with paragraph VII.
V-a. Health carriers shall not underwrite insureds at time of renewal.
VI. Where a health carrier decides to discontinue a particular type of health coverage offered in the individual, large employer or small employer market, the health carrier must:
(a) Provide at least 90-days notice of such discontinuation to each individual or employer with such health coverage and to all covered persons;
(b) Offer to each individual or employer with such health coverage, the option to purchase any other health coverage currently being offered by the health carrier in the relevant market;
(c) Act uniformly without regard to the claims experience of those employers, and without regard to any health status related factor of any covered person or any individual, employee, or eligible dependent who may become a covered person; and
(d) Make no adjustments in the health status factor applied to individuals moving from a discontinued product of that health carrier to another product of that health carrier if the individual was newly covered under the previous product within the last 5 years, or a health status factor adjustment was made with respect to that individual within the last 5 years.
VII. Where a health carrier decides to discontinue all of its health coverage in the individual market, small employer market, large employer market or any combination thereof, the health carrier must provide at least 180-days notice of such discontinuation to the commissioner, to each individual or employer with such health coverage and to all covered persons; and
(a) The health carrier may not renew any health coverages issued, or delivered for issuance, in such discontinued market or markets; and
(b) The health carrier may not provide health coverage in such discontinued market or markets during the 5-year period beginning on the date of the discontinuation of the last health coverage not so renewed except that the commissioner may waive or otherwise reduce the 5-year period in which the health carrier may not provide coverage in the discontinued market for good cause shown.
VIII. A health carrier may, at the time of coverage renewal, modify the health coverage it offers to:
(a) Large employers; and to
(b) Small employers and individuals, provided that such modification is in accordance with state law and applied uniformly among all small employers and/or individuals with such health coverage.
IX. A health carrier which has discontinued coverage in the individual market, the small employer market, or any combination thereof, in accordance with paragraph VII, shall continue to be liable for the payment of claims in accordance with the following:
(a) This section shall apply only to terminating carriers of insureds who obtain creditable replacement health coverage. This paragraph shall be effective with respect to all in-force policies, certificates, or other evidences of coverage as of the effective date of this paragraph.
(b) The terminating carrier shall continue to be liable for the payment of claims if the succeeding carrier's policy requires the satisfaction of any deductibles, individual or family stop-loss provisions limiting out-of-pocket payments, or waiting periods in its plan but only to the extent satisfaction or partial satisfaction of the same or similar provisions were included in the terminated plan providing similar benefits. In the case of deductible provisions and stop-loss provisions, the liability shall be for the same or overlapping benefit periods and shall be for expenses actually incurred and applied against the deductible and stop-loss provisions of the terminating carrier's plan but only to the extent those expenses are recognized under the terms of the succeeding carrier's plan and are subject to a similar stop-loss or deductible provision. The terminating company shall inform its insureds at the time of cancellation that this provision is applicable to them and that this is a requirement of New Hampshire statute. The provision should also appear in all policies or certificates where the provision about termination of the insurance company appears. Nothing in this subparagraph shall be deemed to prevent a succeeding carrier's plan from having stop-loss levels or deductible amounts that are higher than those specified in the terminating carrier's plan.
(c) Whenever a determination of the terminating carrier's benefits is required by the succeeding carrier, at the succeeding carrier's request the terminating carrier shall furnish, in a timely manner, but in no event later than 30 days, a statement of the benefits available or pertinent information, sufficient to permit verification of the terminating carrier's liability to the succeeding carrier. Any determination of the liability of the terminating plan shall be made in accordance with all the definitions, conditions, and covered expense provisions of the terminating plan rather than those of the succeeding plan. The benefit determination shall be made as if coverage had not been replaced by the succeeding carrier. The succeeding carrier shall notify the terminating carrier as to its liabilities pursuant to RSA 420-G:6, IX(b) and shall indemnify the insured for the same. Upon determination of any liability of the terminating plan, the terminating plan shall pay the succeeding plan in a timely manner, in no event later than 15 days, upon receipt of said claim information.

Source. 1997, 344:1. 1998, 158:1; 329:2; 340:12-14; 375:2-4. 2001, 295:3, 13. 2002, 1:1. 2005, 248:17. 2009, 235:16, eff. Sept. 14, 2009. 2019, 220:6, 7, eff. Sept. 10, 2019.

Section 420-G:7

    420-G:7 Preexisting Condition Exclusion Periods. – A health carrier shall not impose any preexisting condition exclusion with respect to coverage in the individual, small group, or large group market.

Source. 1997, 344:1. 2003, 188:11, 12. 2007, 289:23, eff. Jan. 1, 2008. 2019, 220:8, eff. Sept. 10, 2019.

Section 420-G:8

    420-G:8 Open Enrollment. –
I. Each small employer group shall have an annual employee open enrollment period 60 days in length, occurring prior to the small employer group's anniversary date. During open enrollment, employees or eligible dependents may apply to the small employer for health coverage or make a change in their membership status becoming effective upon the small employer group's anniversary date, subject to providing the health carrier 30-days notice.
(a) A health carrier shall not refuse any small employer employees or eligible dependents applying for health coverage during the open enrollment period.
(b) Employees or eligible dependents coming on at the time of an open enrollment period shall have the same premiums as the rest of the small employer group shall have upon the new or renewal effective date.
II. A small employer employee who has met any employer imposed waiting period and is otherwise eligible for health coverage, who declines a small employer's health coverage plan during the initial offering or subsequent open enrollment period, shall be a late enrollee and shall not be allowed on the plan until the next open enrollment period.
III. A large employer employee, who has met any employer imposed waiting period and is otherwise eligible for health coverage, may enroll within 31 days of becoming eligible and shall not be required to submit evidence of insurability based on medical conditions. If a person does not enroll at this time, that person is a late enrollee. Each large employer group shall have an open enrollment period during which late enrollees may enroll and shall not be required to submit evidence of insurability based on medical conditions.
IV. Paragraphs II and III notwithstanding, an eligible employee or eligible dependent shall not be considered a late enrollee if:
(a) The person was covered under public or private health coverage at the time the person was able to enroll; and
(1) Has lost public or private health coverage as a result of termination of employment or eligibility, the termination of the other plan's coverage, death of a spouse, or divorce; and
(2) Requests enrollment within 30 days after termination of such health coverage; or
(b) Is employed by an employer that offers multiple health coverages and the person elects a different plan during an open enrollment period; or
(c) Was ordered by a court to provide health coverage for an ex-spouse or a minor child under a covered employee's plan and the request for enrollment is made within 30 days after issuance of such court order.
V. (a) If individual coverage offered by a health carrier or a large or small employer group's health coverage plan offers dependent coverage and the individual is enrolled in such coverage or the employee is enrolled or has met any applicable waiting period and is eligible to be enrolled, but for a failure to do so during a previous open enrollment period, a person who becomes a dependent of the individual or employee through marriage, birth, adoption or placement for adoption, and the employee if not otherwise enrolled, shall be provided with a special enrollment period.
(b) If an individual has minimum essential coverage through individual coverage offered by a health carrier or as an employee through a large or small employer group's health coverage plan, and the individual loses such coverage for any reason other than failure to pay premiums or a basis on which rescission is permitted pursuant to RSA 420-G:6, IV, the individual shall be provided with a special open enrollment period under any other individual health coverage or any large or small employer group health coverage plan for which the individual becomes eligible.
(c) The special enrollment period shall be at least 60 days in length and shall begin on the later of:
(1) The date dependent health coverage is made available; or
(2) The date of the marriage, birth, adoption, placement for adoption, or loss of minimum essential coverage, as the case may be.
(d) If the person seeks enrollment during such special enrollment period, the health coverage shall become effective:
(1) In the case of marriage or loss of minimum essential coverage, on or before the first day of the first month following the completed request for enrollment;
(2) In the case of birth, as of the date of birth; or
(3) In the case of adoption or placement for adoption, the date of such adoption or placement for adoption.

Source. 1997, 344:1. 2001, 296:3. 2003, 188:16. 2007, 289:39, eff. Jan. 1, 2008. 2019, 220:9, eff. Sept. 10, 2019.

Section 420-G:9

    420-G:9 Minimum Participation Requirements. –
I. A health carrier may not require more than the minimum participation percentage of the employees eligible for health coverage in a small employer group to participate in the health carrier's health coverage plan. The minimum participation percentage shall be 75 percent when the health carrier's plan is the sole health coverage plan being sponsored by the employer group, and 37.5 percent when the health carrier's plan is not the sole health coverage plan being sponsored by the employer group.
II. For the purpose of calculating whether or not a small employer group's enrollment meets a carrier's minimum participation requirements:
(a) Any full-time or part-time employees who are covered as a dependent on another person's health coverage shall be excluded from the count.
(b) The total number of full-time employees and part-time employees who are otherwise eligible for health coverage shall be counted.
III. The minimum participation requirements shall be calculated on an employer-by-employer basis if the small employer is part of an association, trust, or other similar arrangement.
IV. In performing the computation to determine the actual enrollment necessary to meet the minimum participation requirement as a small employer group, the health carrier shall round any fractional number to the higher integer.
V. For the purpose of calculating whether or not a small employer group's enrollment meets a carrier's minimum participation requirements:
(a) Any full-time or part-time employee who is covered as a dependent on another person's health coverage or is enrolled in a governmental plan such as Medicare, Medicaid, or TRICARE shall be excluded from the count.
(b) Any full-time or part-time employee who has been found eligible for a premium tax credit and is enrolled in a qualified health plan (QHP) purchased through an exchange shall be excluded from the count.
(c) The total number of full-time employees and part-time employees who are otherwise eligible for health coverage shall be counted.
VI. The requirements under this section shall be the only participation requirements. Minimum employer contributions, or other criteria, shall not be permitted.

Source. 1997, 344:1. 1998, 340:15, eff. Aug. 25, 1998. 2019, 220:10, eff. Sept. 10, 2019.

Section 420-G:10


[RSA 420-G:10 effective until 60 days after certification by the insurance commissioner that 29 C.F.R. section 2510.3-5(b) is valid and that issues raised in State of New York v. United States Department of Labor have been resolved, but not later than December 1, 2021; see also RSA 420-G:10 set out below.]
    420-G:10 Qualified Association Trust and Qualified Purchasing Alliance. –
I. A qualified association trust or other entity, as defined in RSA 420-G:2, XV, and a qualified purchasing alliance, as defined in RSA 420-M:2, X, shall:
(a) Comply with the rating restrictions outlined in RSA 420-G:4 for all small employer members with 50 or fewer employees based upon the association's or alliance's group experience, except that for a qualified association trust, no rating factor shall be utilized without the express written consent of the association.
(b) Offer all eligible members, as defined under the applicable trust or other documents, coverage and rates on a guaranteed issue and renewable basis.
(c) Comply with the regulations concerning medical underwriting in RSA 420-G:5.
(d) Comply with the preexisting conditions provision of RSA 420-G:7.
(e) Prohibit any employer that voluntarily discontinues participation in either a qualified association trust or a qualified purchasing alliance from rejoining for a period of at least 24 months.
II. Nothing in this chapter shall be interpreted to limit the size of employers who may participate in coverage with a qualified association trust or a qualified purchasing alliance.

[RSA 420-G:10 effective 60 days after certification by the insurance commissioner that 29 C.F.R. section 2510.3-5(b) is valid and that issues raised in State of New York v. United States Department of Labor have been resolved, but not later than December 1, 2021; see also RSA 420-G:10 above.]


420-G:10 Qualified Association Trust. –
I. A qualified association trust or other entity, as defined in RSA 420-G:2, XV shall:
(a) Comply with the rating restrictions outlined in RSA 420-G:4 for all small employer members with 50 or fewer employees based upon the association's or alliance's group experience, except that no rating factor shall be utilized without the express written consent of the association.
(b) Offer all eligible members, as defined under the applicable trust or other documents, coverage and rates on a guaranteed issue and renewable basis.
(c) Comply with the regulations concerning medical underwriting in RSA 420-G:5.
(d) Comply with the preexisting conditions provision of RSA 420-G:7.
II. Nothing in this chapter shall be interpreted to limit the size of employers who may participate in coverage with a qualified association trust.

Source. 1997, 344:1. 2003, 188:8. 2010, 346:10, eff. July 20, 2010. 2019, 346:413.

Section 420-G:10-a

    420-G:10-a Voluntary Small Employer Health Insurance Purchasing Alliances; Rulemaking. –
I. The commissioner shall have the regulatory oversight authority to set standards for the licensure and conduct of purchasing alliances authorized under this section and to enforce such standards.
II. Each applicant and each duly licensed purchasing alliance shall file with the commissioner such information or documents as the commissioner shall adopt by rule as necessary to perform oversight function.
III. [Repealed.]
IV. [Repealed.]
V. The commissioner shall adopt such rules, under RSA 541-A, and issue such orders as may be necessary to carry out the commissioner's oversight responsibilities under this section.

Source. 2000, 2:2. 2010, 346:3, II, eff. July 20, 2010.

Section 420-G:11

    420-G:11 Disclosure. –
I. Health carriers operating in the small employer and/or individual markets shall make reasonable disclosure in solicitation and sales materials provided to individuals and small employers of the following:
(a) The methodology by which premium rates for an individual or specific small employer are established. Each health carrier shall state that rates and practices are in full compliance with this chapter.
(b) The provisions concerning the health carrier's right to change premium rates and the factors which affect changes in premium rates.
(c) The provisions relating to renewability of health coverage.
(d) The provisions relating to any preexisting condition exclusions.
(e) The benefits and premiums available under all health insurance coverage for which the employer is qualified.
II. (a) All health carriers, licensed third party administrators, and any entity required to be registered with the commissioner pursuant to RSA 402-H, shall electronically provide:
(1) Their encrypted claims data to the department and to the department of health and human services in accordance with rules approved by the commissioner of health and humans services and adopted under RSA 420-G:14.
(2) To the department of health and human services, cross-matched claims data on requested policyholders, and subscriber information necessary for third party liability for benefits provided under RSA 167, filed in accordance with rules adopted under RSA 167:3-c.
(b) Notwithstanding RSA 91-A:10, the collection storage and release of health care data and statistical information that is subject to the federal requirements of the Health Information Privacy and Accountability Act (HIPAA) shall be governed exclusively by the rules adopted thereunder in 45 CFR Parts 160 and 164.
II-a. All health carriers and other health plans that collect the Health Employer Data and Information Set (HEDIS) shall annually submit the HEDIS information to the department.
III. All health carriers shall accept electronic claims submitted in Centers for Medicare and Medicaid Services (CMS) format for UB-92 or HCFA-1500 records, or as amended by CMS.
IV. The data submission requirements of paragraphs II and II-a shall apply with respect to claims data for all lives covered by a fully-insured health plan in any market in the state, by any self-funded plan for state or municipal employees, including any plan maintained under RSA 5-B, to any self-funded plan maintained by the university system of the state with respect to its employees or its students, and to any self-funded student health benefit plan maintained by an institution of higher education which provides 4-year bachelor's degree programs and graduate or professional degree programs.
V. In addition to those lives listed in paragraph IV, the data submission requirements of paragraphs II and II-a shall also apply to all health carriers, licensed third party administrators, and any entity required to be registered with the commissioner pursuant to RSA 402-H with respect to claims data for all lives covered by any other self-funded employer-sponsored plan, when the employer has opted in writing to the submission of the data. The carrier or administrator shall notify the employer of the employer's option to authorize submission of the data. The commissioner shall adopt rules under RSA 541-A specifying the form of such opt in, which shall include, but not be limited to, notice to the employer regarding why it is receiving the notification form, the privacy protections for the data submitted should the employer choose to opt in, and the transparency benefits, including benefits to employers, of broad inclusion of as many lives as possible in the database created under RSA 420-G:11-a. Nothing in this paragraph shall be construed to impose any reporting obligation on any self-funded employer or plan sponsor, or to impose any requirement with respect to the manner in which any such self-funded plan is administered. Nothing in this paragraph shall prevent a health carrier or third party administrator from communicating its views to an employer about the employer's decision whether to opt in to the submission of claims data.

Source. 1997, 344:1. 1999, 318:4. 2003, 145:3, 4; 292:3, 4, 7. 2006, 271:13, eff. Aug. 8, 2006. 2016, 250:2, eff. June 10, 2016.

Section 420-G:11-a

    420-G:11-a Development of a Comprehensive Health Care Information System. –
I. The department, the department of justice, and the department of health and human services shall enter into a memorandum of understanding for collaboration in the development of a comprehensive health care information system, the sharing of submitted data fields, and the role of each in the security of transferred health care data. The memorandum of understanding shall include a description of the data sets that will be included in the comprehensive health care information system, the criteria and procedures for the development of limited use data sets, the criteria and procedures to ensure that Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant limited use data sets are accessible, and a proposed time frame for the creation of a comprehensive health care information system. To the extent allowed by HIPAA, the data shall be available as a resource for insurers, employers, providers, purchasers of health care, and state agencies to continuously review health care utilization, expenditures, and performance in New Hampshire and to enhance the ability of New Hampshire consumers and employers to make informed and cost-effective health care choices. In presenting data for public access, comparative considerations shall be made regarding geography, demographics, general economic factors, and institutional size. Notwithstanding HIPAA or any other provision of law, the comprehensive health care information system shall not include or disclose any data that contains direct personal identifiers. For the purposes of this section, "direct personal identifiers" include information relating to an individual that contains primary or obvious identifiers.
II. The commissioner of the department of health and human services, with the approval of the commissioner of the insurance department, shall adopt rules, under RSA 541-A, as may be necessary to provide for the release of claims data from the comprehensive health care information system (CHIS).
III. The department shall make available to the public a public use data set for purposes of facilitating transparency in health care costs.

Source. 2003, 292:6. 2005, 248:19. 2015, 210:1, eff. Sept. 4, 2015. 2019, 233:6, eff. July 12, 2019.

Section 420-G:12

    420-G:12 Rating Practices and Filings. –
I. Each health carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation which demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
II. Each health carrier shall file each March 1, with the commissioner, an actuarial certification stating that the health carrier is in compliance with this section and that the rating methods of the health carrier are actuarially sound.
III. A health carrier shall make the information and documentation described in paragraph I available to the commissioner upon request.
IV. Each health carrier shall provide, at the time it gives a premium quote to a group, a rating disclosure form that identifies the health coverage plan rate and any adjustments to that rate resulting from the application of rating factors, including age, industry, and group size. The health carrier shall submit the rate disclosure form to the department for approval. Health carriers shall provide their insureds with renewal premium quotes at least 60 days prior to the expiration date of the policy.

Source. 1997, 344:1. 2006, 125:2, eff. July 14, 2006.

Section 420-G:12-a

    420-G:12-a Health Plan Loss Information. –
I. To ensure maximum competition in the purchase of group health insurance, all large employers shall be entitled to receive their specific health plan loss information upon request and without charge. No contract between any health carrier, third-party administrator, employer group, or pool of employers shall abridge this right in any manner.
II. Upon written request from any large employer, every health carrier, third-party administrator, pooled risk management program under RSA 5-B or any other type of multiple employer health plan shall provide that employer's loss information within 30 calendar days of receipt of the request. The loss information shall include all physician, hospital, prescription drug, and other covered medical claims specific to the employer's group plan incurred for the 12-month period paid through the 14 months which end within the 60-day period prior to the date of the request. An employer shall not be entitled by this section to more than 2 loss information requests in any 12-month period; however, nothing shall prohibit a carrier from fulfilling more frequent requests on a mutually agreed-upon basis.
III. If an employer requests loss information from an insurance agent or other authorized representative, including an administrator of a pooled risk management program or a multiple employer health plan, the agent or authorized representative shall transmit the request to the health carrier or carriers or third-party administrator within 4 working days.

Source. 2001, 120:2. 2003, 127:1; 188:9. 2004, 187:14, eff. July 31, 2004.

Section 420-G:13

    420-G:13 Approval of Rate Filings. – No policy or contract of insurance or any certificate under such policy or contract or other evidence of coverage shall be issued to a small employer or an individual under this chapter until the premium rates have been filed and approved by the commissioner. The commissioner shall approve or disapprove such rates within 30 days of receipt. The commissioner may disapprove rate filings if the commissioner finds such rates to be excessive, inadequate, or contrary to the intent of this chapter.

Source. 1997, 344:1, eff. July 1, 1997.

Section 420-G:14

    420-G:14 Rulemaking Authority. –
I. (a) The commissioner may adopt rules, under RSA 541-A, relative to:
(1) Uniform age rating levels that are consistent with 45 C.F.R. 147.102.
(2) Special enrollment periods designed to allow employees to purchase individual coverage on the exchange during their employer's open enrollment period, even if the employer's open enrollment period does not coincide with the open enrollment period in the individual market.
(3) Essential health benefits, in accordance with RSA 420-G:4-d, II and III.
(b) The commissioner may adopt further rules, pursuant to RSA 541-A, necessary to the proper administration of this chapter.
II. The commissioner, with the approval of the commissioner of the department of health and human services, shall adopt rules, under RSA 541-A, defining the content, format, and schedule for the filing of encrypted claims data and HEDIS information under RSA 420-G:11.

Source. 1997, 344:1. 2002, 207:50. 2003, 292:5, eff. July 18, 2003. 2019, 220:11, eff. Sept. 10, 2019.

Section 420-G:14-a

    420-G:14-a Requested Information. –
I. As authorized in accordance with RSA 420-G:14, the commissioner may request the submission of such information by carriers as is necessary to better understand the coverage history and choices of participants in the nongroup market. The commissioner shall make every attempt to ensure the reasonableness of such request, both in terms of scope and timeframe, and to limit this request to information the commissioner deems necessary to better understand the dynamics of the nongroup health insurance market and to assess the appropriateness of alternative sources of funding for the nongroup subsidy.
II. The commissioner shall request and health carriers shall supply information and data no later than June 30 of each year sufficient to report on the small employer health insurance market. Such information shall be reported for the market as a whole and by market segment. At the commissioner's discretion, such information may include, but not be limited to, information relating to premium rates and rating practices, the number of groups and individuals insured, availability of coverage and benefit plans, trend, loss ratios, administration costs, and profitability. The commissioner shall file a report of the information by December 31 of each year with the president of the senate, the speaker of the house of representatives, the chairperson of the house commerce committee, and the chairperson of the senate banks and insurance committee.
III. The commissioner shall request and health carriers shall supply information no later than June 30 of each year sufficient to report on the types of health coverage being purchased by individuals and employers by geographic area. The report shall include specific details regarding the type of coverage, including, but not limited to, co-pays, out-of-pocket maximums, network restrictions, and deductibles.
IV. The commissioner shall file the required reports by December 31 of each year with the senate president, the speaker of the house, and the chairpersons of the house and senate committees having jurisdiction over commerce issues.
V. The commissioner shall hold an annual public hearing concerning premium rates in the health insurance market and the factors, including health care costs and cost trends, that have contributed to rate increases during the prior year. The commissioner shall evaluate claims costs, administrative loads, and health carrier profits. The commissioner shall identify the factors that contribute to cost increases affecting health insurance premiums and health care services in New Hampshire. The commissioner shall identify variations in the price that health carriers pay for health care services and shall undertake further analysis to determine the cause of the observed price variations by utilizing the uniform hospital discharge data set, as described under RSA 126:25, the comprehensive health care information system as described in RSA 420-G:11-a, and other data sources as appropriate. In advance of holding the public hearing, the commissioner may require any health insurer or third party administrator to produce documents and information deemed necessary and relevant to evaluate the factors that contribute to cost growth in health care services, increased utilization of health care, and health insurance premium costs. The commissioner shall keep confidential all nonpublic documents and shall not disclose those documents without the consent of the health care provider or health care payer that produced the information or documents. The commissioner may compel a health insurance carrier or third party administrator to testify at the annual public hearing. The commissioner may also invite representatives of health care providers to provide relevant information.
VI. (a) The commissioner shall prepare an annual report concerning premium rates in the health insurance market and the factors that have contributed to rate variations during prior years. The annual report shall be designed to provide information which identifies and quantifies health care spending trends and the underlying factors that contributed to variations in health insurance premiums. The report may include, as appropriate, analysis of public policy options for increasing the efficiency of New Hampshire's health care financing and delivery system and controlling health care costs and premium variations. The report shall be based to the highest extent possible on the commissioner's analysis of information and data available to the commissioner, including the testimony at the public hearing, and any other information or documents submitted in connection with the public hearing.
(b) The commissioner shall submit the annual report to the governor, the president of the senate, and the speaker of the house of representatives on or before December 31 of each year.
VII. In conjunction with the annual public hearing required under paragraph V and the report required under paragraph VI, the commissioner shall consider any pertinent work of other legislative commissions and inquires focused on related matters.

Source. 1998, 340:16. 2003, 188:10. 2006, 125:3. 2007, 289:24. 2010, 240:1. 2014, 254:2, eff. July 22, 2014. 2019, 7:1, eff. July 9, 2019.

Section 420-G:14-b

    420-G:14-b Prohibited Transactions. – No health care provider shall submit a claim for reimbursement, or otherwise accept payment, for health care services provided to a patient covered by individual health insurance if the provider has paid the premium for such individual health insurance.

Source. 1998, 340:16, eff. Aug. 25, 1998.

Section 420-G:14-c

    420-G:14-c Repealed by 2003, 188:17, eff. Jan. 1, 2009. –

Section 420-G:15

    420-G:15 Severability. – If any provision of this chapter or the application thereof to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the chapter which can be given effect without the invalid provisions or applications, and to this end the provisions of this chapter are severable.

Source. 1997, 344:1, eff. July 1, 1997.

Section 420-G:16

    420-G:16 Penalties for Violations. –
Any health carrier who proposes, advertises, solicits, issues or delivers to any person or entity in this state any form which does not comply with this chapter or who shall in any way violate this chapter may:
I. Be prohibited from marketing, selling, or otherwise administering to the individual or small employer market if the commissioner finds a health carrier to be in violation of RSA 420-G.
II. Be subject to an administrative fine not to exceed $2,500 for each violation. Repeated violations of the same chapter shall constitute separate fineable offenses.
III. Have its certificate of authority indefinitely suspended or revoked at the discretion of the commissioner.

Source. 1997, 344:1, eff. July 1, 1997.