TITLE XXXVII
INSURANCE

Chapter 420-A
HEALTH SERVICE CORPORATIONS

Section 420-A:1

420-A:1 Definitions. –
In this chapter:
I. "Commissioner" means the insurance commissioner.
II. "Covered dependent" means the spouse, an adult dependent, or a child or an adopted child of the subscriber who is named in the subscription certificate issued to the subscriber and with respect to whom appropriate premium is specified in the certificate.
II-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.
III. "Health service corporation" means a nonprofit sharing corporation without capital stock organized under the laws of the state for the purpose of establishing, maintaining, and operating a health service plan or plans whereby the expense of health-related care may be partially or wholly provided to its subscribers by the payment of benefits for facilities, professional services, appliances, medicines, or supplies furnished directly or indirectly by the health service corporation to its subscribers.
IV. "Provider" means any physician, hospital, or other institution, organization, or other person who furnishes health care services.
V. "Subscriber" means a person to whom a subscription certificate is issued by the health service corporation and which sets forth the kinds and extent of health services for which the health service corporation is liable to make payment and which constitutes the contract between the subscriber and the health service corporation.

Source. 1997, 190:1. 2007, 289:12, eff. Jan. 1, 2008.

Section 420-A:2

420-A:2 Applicable Statutes. – Every health service corporation shall be governed by this chapter and the relevant provisions of RSA 161-H, and shall be exempt from this title except for the provisions of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415-A, RSA 415-F, RSA 415:6, II(4), RSA 415:6-g, RSA 415:6-k, RSA 415:6-m, RSA 415:6-o, RSA 415:6-r, RSA 415:6-t, RSA 415:6-u, RSA 415:6-v, RSA 415:6-w, RSA 415:6-x, RSA 415:6-y, RSA 415:6-z, RSA 415:6-a1, RSA 415:18, V, RSA 415:18, XVI and XVII, RSA 415:18, VII-a, RSA 415:18-a, RSA 415:18-i, RSA 415:18-j, RSA 415:18-o, RSA 415:18-r, RSA 415:18-t, RSA 415:18-u, RSA 415:18-v, RSA 415:18-w, RSA 415:18-y, RSA 415:18-z, RSA 415:18-aa, RSA 415:18-bb, RSA 415:18-cc, RSA 415:18-dd, RSA 415:18-ee, RSA 415:22, RSA 417, RSA 417-E, RSA 420-J, and all applicable provisions of title XXXVII wherein such corporations are specifically included. Every health service corporation and its agents shall be subject to the fees prescribed for health service corporations under RSA 400-A:29, VII.

Source. 1997, 190:1; 345:9. 1999, 323:7. 2000, 207:6. 2003, 286:4. 2006, 187:3. 2007, 289:35. 2008, 389:3. 2010, 362:3. 2011, 133:3; 189:8, 10. 2012, 278:3. 2014, 299:3, eff. Sept. 30, 2014; 299:6, eff. Oct. 1, 2017. 2015, 263:8, eff. Jan. 1, 2017; 263:9, eff. Oct. 1, 2017 at 12:01 a.m.; 263:12, eff. Jan. 1, 2021. 2016, 326:3, eff. Aug. 23, 2016; 326:4, eff. Oct. 1, 2017 at 12:02 a.m.; 326:5, eff. Jan. 1, 2021 at 12:01 a.m.; 326:9, eff. Jan. 1, 2017 at 12:01 a.m. 2018, 4:13, eff. Feb. 8, 2018; 4:14, eff. Jan. 1, 2021 at 12:02 a.m.; 361:4, eff. Jan. 1, 2019; 361:5, eff. Jan. 1, 2021 at 12:02 a.m. 2019, 113:4, eff. Aug. 20, 2019; 113:5, eff. Jan. 1, 2021 at 12:03 a.m. 2020, 13:11, eff. Jan. 1, 2021; 13:12, eff. Jan. 1, 2021 at 12:04 a.m.; 30:11, eff. Sept. 21, 2020; 30:12, eff. Jan. 1, 2021 at 12:04 p.m.; 39:7, eff. Jan. 1, 2021 at 12:04 a.m.; 39:22, eff. June 30, 2021; 39:23, eff. Jan. 1, 2021 at 12:05 p.m.

Section 420-A:3

420-A:3 Incorporation. –
Persons desiring to form a health service corporation may incorporate under RSA 292, but subject to the following provisions:
I. The certificate of incorporation of each health service corporation shall have endorsed upon it or attached to it the approval of the commissioner, if the commissioner finds the same to be in accordance with this chapter.
II. The certificate shall include a statement of the territory in which the health service corporation will operate and a statement of the purposes of such corporation.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:4

420-A:4 License to Health Service Corporation. –
I. No health service corporation organized under the laws of this state shall do business unless it has obtained a license from the commissioner.
II. No health service corporation organized under the laws of any other state or country shall be licensed to do business in this state except as provided in RSA 420-A:29.
III. Application for such license shall be made in the form required by the commissioner and shall contain the information the commissioner deems necessary. The application shall be accompanied by a copy of each of the following documents:
(a) Articles of incorporation.
(b) Bylaws.
(c) Proposed contracts to be issued to subscribers showing a table of rates to be charged and the benefits to which they will be entitled.
(d) Proposed contracts, if any, between the health service corporation and providers.
(e) Financial statements.
IV. The commissioner shall issue a license when the commissioner finds:
(a) The applicant is established as a bona fide nonprofit health service corporation;
(b) The applicant has paid an annual license fee in accordance with RSA 400-A:29;
(c) The contracts between the applicant and providers, if any, obligate the respective providers to provide the service or thing to which the subscriber may be entitled under the terms of the contract to be issued to subscribers;
(d) The rates to be charged and the benefits to be provided are reasonable and nondiscriminatory;
(e) The financial condition of the applicant is sound and provides assurance of its ability to meet its obligations; and
(f) The applicant is reliable, entitled to public confidence and has complied with the laws of the state applicable to it.
V. Any such license may be revoked for cause shown and after notice and hearing upon failure to maintain the requirements of this chapter.
VI. All such licenses shall expire on June 14, but may be renewed upon payment of the annual license fee.

Source. 1997, 190:1. 2000, 162:4, eff. July 22, 2000.

Section 420-A:5

420-A:5 Directors. –
The directors of a health service corporation:
I. Shall at all times include representation from the following groups:
(a) The general public exclusive of those falling within subparagraphs (b) and (c) and paragraph II.
(b) Physicians actively engaged in practice.
(c) Administrators or trustees of hospitals, if any, which have contracted with the health service corporation to render nonprofit hospital service or indemnity to subscribers.
II. May include representatives of other health care providers. The number of directors described in subparagraph I(a) shall exceed the combined total of the number of directors described in subparagraphs I(b) and (c) and this paragraph.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:6

420-A:6 Liability of Directors, Officers, and Trustees. –
I. A health service corporation may indemnify any person who serves as director, officer, or trustee of such corporation by contract or by including an indemnity provision in its articles of agreement or bylaws substantially in accordance with RSA 293-A:8.50 through RSA 293-A:8.58. Indemnity may be offered for any and all damages occurring on or after January 1, 1991.
II. A health service corporation may amend its articles of agreement to contain a provision eliminating or limiting the personal liability of a director, officer, or trustee to such corporation and its members and subscribers for monetary damages for breach of fiduciary duty as a director, an officer, or both, except with respect to:
(a) Any breach of the director's, officer's or trustee's duty of loyalty to the corporation and its members and subscribers.
(b) Acts or omissions which are not in good faith or which involve intentional misconduct or a knowing violation of law.
(c) Actions for which a director, officer, or trustee derived an improper personal benefit.
III. Paragraph II shall not be construed to eliminate or limit the liability of a director, an officer, a trustee or any combination thereof, for any act or omission occurring prior to July 13, 1991.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:7

420-A:7 License to Agents. –
I. No person, for himself or in behalf of any person, shall sell or offer to sell any such health service as is provided for in this chapter without being licensed therefor by the commissioner pursuant to RSA 402-J.
II. Upon written notice by a health service corporation licensed to do business in this state of its appointment of a person to act as its agent under this chapter, the commissioner shall, if the commissioner is first satisfied that the appointee is a suitable person and intends to hold himself out in good faith as an agent, upon payment of the proper fee by the applicant, issue to the appointee a license to act as such agent.
III. A license previously issued may be renewed upon the application of the health service corporation upon payment of the proper fee.
IV. The commissioner may at any time after granting such license, for cause shown and after notice and hearing, determine such licensee to be unsuitable to act as such agent, and shall thereupon revoke such license and notify both the health service corporation and the agent of such revocation.
V. Unless revoked by the commissioner, or unless the health service corporation by written notice to the commissioner cancels the agent's authority to act for it, such license issued to an agent, or any renewal of such license, shall expire on June 14 of the second year after its issue.
VI. If a person acts or aids in any manner in the negotiation of health insurance contracts, or solicits or receives any risk or application for such service, without a license from the insurance commissioner, or if the license granted to such person or to the health service corporation for which the person acts as agent has been revoked, such person shall be guilty of a class A misdemeanor if a natural person, or guilty of a felony if any other person; but any contract issued on an application thus procured shall bind the health service corporation if otherwise valid. This paragraph shall not apply to any office employee of the health service corporation, or to any persons rendering their services without compensation.

Source. 1997, 190:1. 2000, 315:22. 2005, 206:8, eff. Jan. 1, 2006.

Section 420-A:8

420-A:8 Filing and Approval of Contracts and Rates. –
I. No health service corporation shall enter into any contract with subscribers until it shall have filed with the commissioner a copy of the form of such contract, including all riders and endorsements to the contract and until the commissioner's approval thereof shall have been obtained. Any form of contract not disapproved by the commissioner within 90 days after the filing shall be deemed to have been approved as filed.
II. No health service corporation shall enter into any contract with subscribers until it shall have filed with the commissioner a full schedule of rates to be paid by the subscribers and shall have obtained the said commissioner's approval. The commissioner may refuse such approval if the commissioner finds such rates are excessive, inadequate, or discriminatory. For the purpose of determining the proper rates to be charged for such services, the commissioner may employ a competent actuary who shall be paid by the health services corporation for which the services are rendered.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:9

420-A:9 Contracts With Subscribers. –
Every contract between a health service corporation and a subscriber shall be in writing, a copy of which shall be furnished to the subscriber and shall contain the following provisions:
I. A statement of the amount payable to the health service corporation by the subscriber and the manner in which such amount is payable.
II. A statement of the nature and extent of the benefits to be provided, and, if any benefits are to be limited or excepted, an enumeration of such limitations or exceptions shall be printed with the same prominence as the statement of the benefits conferred.
III. A statement that a maternity benefits rider will be made available at the subscriber's request, if maternity care is not covered under the contract. Nothing in this paragraph shall be construed to apply to supplemental health insurance and disability insurance policies.
IV. A statement of the terms and conditions upon which the contract may be cancelled or otherwise terminated at the option of either party.
V. A statement that the contract includes the endorsements thereon and attached papers, if any, and that it comprises the entire contract.
VI. A provision that no statement by the subscriber in the application for a contract shall void the contract or be used in any legal proceeding thereunder unless such application or an exact copy is included or attached to the contract.
VII. A statement of the period of grace which will be allowed the subscriber for making any payment due under the contract. Such period shall be not less than 10 days.
VIII. 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 as an advanced practice registered nurse, reimbursement under such policy shall not be denied when such service is rendered by a person so licensed.
IX. No health service corporation shall, when issuing or renewing a policy or contract of insurance or any certificate under such policy or contract covered by this chapter, deny coverage or limit coverage to any resident of 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 a health service corporation accepts an application for group coverage, such acceptance shall be subject to the following:
(a) If the group has coverage in effect through another plan, the health service corporation shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the health service corporation 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 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, such person is a late enrollee.
(c) Once a group policy has been issued, the health service corporation 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 only, the pre-existing condition provisions shall apply for 18 months from the date of enrollment.
X. 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 commissioner.
XI. A statement allowing subscribers with Medicare supplement insurance benefits a period of at least one year after the incurral of a covered expense within which the subscriber shall furnish any proof of loss required by the insurer. Failure to furnish such proof within such time shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and such proof was furnished as soon as was reasonably possible.
XII. A provision that such contract shall be signed by the president and secretary before it shall become effective.
XIII. A statement that all benefits payable shall be paid to the participating providers except those in reimbursement of payments made by the subscriber to a non-participating provider and for which the corporation was liable at the time of payment.

Source. 1997, 190:1. 2009, 54:5, eff. July 21, 2009.

Section 420-A:10

420-A:10 Part-Time Employees. – A health service corporation shall not exclude part-time employees and shall offer the same insurance 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 such employee were a full-time employee, but who works a minimum of at least 15 hours per week.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:10-a

420-A:10-a Dependent Coverage. –
I. A policy may, at the election of the carrier, insure, originally or by subsequent amendment, upon 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 upon 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.
I-a. The coverage of any family member insured by such policy, pursuant to paragraph I, who is mentally or physically incapable of earning his or her own living as of the date on 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 such dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of such 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.
II. Nothing in this section shall be construed to require:
(a) Coverage for services provided to a dependent before the effective date of this section; or
(b) That an employer pay all or part of the cost of family coverage that includes a dependent as provided pursuant to this section.
III. A subscriber that elects family coverage during any applicable open enrollment period may enroll any dependent eligible pursuant to this section.
IV. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following:
(a) The dependent is disqualified for dependent status as set forth in paragraph I of this section; or
(b) The date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber.
V. Nothing in this section shall be construed to permit a health insurance carrier to refuse an election for coverage by a dependent pursuant to paragraph III, based upon the dependent's prior disqualification pursuant to subparagraph IV(a).
VI. (a) Notice regarding coverage for a dependent as provided pursuant to this section 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 section.
(b) Such notice shall include information regarding the required special open enrollment period.

Source. 2007, 352:2. 2009, 235:9. 2010, 243:9, eff. Sept. 23, 2010.

Section 420-A:11

420-A:11 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 health service corporation, except for nonpayment of premium, unless the group contract holder 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 contract holder or mailed to the group contract holder's last address as shown in the records of the health service corporation 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 contract, shall be delivered to the group contract holder or mailed to the group contract holder's last address as shown in the records of the health service corporation, at least 30 days prior to the effective date of the cancellation.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:12

420-A:12 Cancellation or Nonrenewal of Non-Group Insurance Contracts. – No non-group accident or health insurance contract, authorized under this chapter, may be cancelled or nonrenewed by the health service corporation except for nonpayment of premium, unless the insured 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 insured or mailed to the insured's last address as shown in the records of the health service corporation at least 30 days prior to the renewal date of the contract.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:13

420-A:13 Repealed by 2010, 61:3, II, eff. May 18, 2010. –

Section 420-A:14

420-A:14 Coverage for Scalp Hair Prostheses. –
I. Every health service corporation and every other similar corporation licensed under the laws of another state, which 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. 1997, 190:1. 2001, 276:4, eff. Sept. 14, 2001.

Section 420-A:15

420-A:15 Coverage During Adoption Proceedings. – All contracts issued by a health service corporation which provide coverage for a family member of the subscriber 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 subscriber 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. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:15-a

420-A:15-a 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, 117:2, eff. Aug. 15, 2004.

Section 420-A:15-b

420-A:15-b Coverage for Dependents. – If the coverage for dependent children 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 section. 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 section. 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 section commences.

Source. 2007, 289:13, eff. Jan. 1, 2008.

Section 420-A:16

420-A:16 Notification of Allowable Benefit. – All health service corporations and every other similar corporation licensed under the laws of another state shall provide to each subscriber, on request, a written statement of the dollar amount of allowable benefit for any procedure which is requested by the appropriate procedure code.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:16-a

420-A:16-a Patients' Bill of Rights. – Every health service corporation and every other similar corporation licensed under the laws of another state shall provide to each new subscriber who is a resident of this state a copy of the patients' bill of rights law under RSA 151:21.

Source. 1997, 331:19, eff. Jan. 1, 1998 at 12:01 a.m.

Section 420-A:17

420-A:17 Coverage for Nonprescription Enteral Formulas. –
I. Every health service corporation and every other similar corporation licensed under the laws of another state that issues or renews any policy of individual or group accident or health insurance providing benefits for medical or hospital expenses shall provide to each individual or 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. Every health service corporation and every other similar corporation licensed under the laws of another state that issues or renews any policy of individual or group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each individual or 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. 1997, 190:1. 2010, 188:7, eff. Aug. 20, 2010.

Section 420-A:17-a

420-A:17-a Coverage for Diabetes Services and Supplies. – Every health service corporation and every similar corporation licensed under the laws of another state that issues or renews any policy, plan, or contract of individual or group accident or health insurance providing benefits for medical or hospital expenses, shall provide to each individual or group, or to the portion of each group comprised of certificate holders of such insurance who are residents of this state, coverage for the 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 health service corporation that issues or renews any individual or 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 health service corporation 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 health service corporation that issues or renews any individual or 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, 258:7. 2010, 188:13, eff. Aug. 20, 2010. 2020, 13:3, eff. Sept. 14, 2020.

Section 420-A:17-b

420-A:17-b Coverage for Dental Procedures. –
I. Every health service corporation and every similar corporation licensed under the laws of another state that issues or renews any group policy of accident or health insurance providing benefits for medical or hospital expenses, shall provide to each covered individual or certificate holder who is a resident 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 primary care 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 primary care 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, 280:3. 2003, 278:4. 2010, 188:8, eff. Aug. 20, 2010. 2018, 188:7, eff. Aug. 7, 2018.

Section 420-A:17-c

420-A:17-c Coverage for Prescription Contraceptive Drugs and Prescription Contraceptive Devices and for Contraceptive Services. – Every health service corporation and every other similar corporation licensed under the laws of another state that issues or renews any policy of group 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 health service corporation and every other similar corporation licensed under the laws of a different state that issues or renews any group policy of 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, 252:2. 2010, 188:13, eff. Aug. 20, 2010. 2018, 205:5, eff. Jan. 1, 2019; 361:10, eff. Jan. 1, 2019 at 12:01 a.m.

Section 420-A:17-d

420-A:17-d Prompt Payment Required. –
I. (a) Every health service corporation, and every other similar corporation licensed under the laws of another state that issues or renews any policy of individual or 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 health service corporation is denying or pending the claim, the corporation 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 subscriber of the reason for denying or pending the claim and what, if any, additional information is required to adjudicate the claim. Upon the health service corporation's receipt of the requested additional information, the health service corporation 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 health services corporation 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 corporation'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 a health service corporation on the corporation'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 corporation'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 corporation 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 health service corporation 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 health service corporation, 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 health service corporation for payment of the claim.
IV. Exceptions to the requirements of this section are as follows:
(a) No health service corporation 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 corporation is in liquidation or rehabilitation or is operating in compliance with a court-ordered plan of rehabilitation; or
(3) The corporation's compliance is rendered impossible due to matters beyond the corporation's control which are not caused by such corporation.
(b) No health service corporation shall be in violation of this section for any claim submitted more than 90 days after the service was rendered.
(c) No health service corporation 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 health service corporation or may suspend or revoke the license or certificate of authority of any health service corporation after determining that the health service corporation 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, 274:4; 314:4. 2005, 162:3. 2010, 188:9. 2012, 99:3, eff. July 28, 2012.

Section 420-A:17-e

420-A:17-e Retroactive Denials Prohibited; Exceptions. –
I. In this section "retroactive denial of a previously paid claim" means any attempt by a health service corporation 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 health service corporation shall impose on any health care provider any retroactive denial of a previously paid claim or any part thereof unless:
(a) The corporation has provided the reason for the retroactive denial in writing to the health care provider; and
(b) The time which has lapsed 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 physician/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 physician/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. A health service corporation 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 health service corporation and provider, the health service corporation 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, 143:3. 2006, 104:3, eff. Aug. 7, 2006.

Section 420-A:17-f

420-A:17-f Coverage for Certified Midwives. – Every health service corporation and every other similar corporation licensed under the laws of another state 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, 8:3. 2008, 298:3. 2010, 188:13, eff. Aug. 20, 2010.

Section 420-A:17-g

420-A:17-g Coverage for Children's Early Intervention Services. – Every health service corporation and every other similar corporation licensed under the laws of another state that issues or renews any policy of group accident or health insurance providing benefits for medical, rehabilitation, 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 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, 338:3. 2010, 188:13, eff. Aug. 20, 2010. 2020, 26:41, eff. Sept. 18, 2020. 2021, 56:10, eff. July 24, 2021.

Section 420-A:18

420-A:18 Investments. – No health service corporation shall invest its funds otherwise than as provided in RSA 411-A relating to the investments and holding of real estate by domestic life insurance companies; provided that not exceeding 10 percent of a health service corporation's total admitted assets may be invested in such investments as are prudent for a domestic life insurance company to make, and provided further that, notwithstanding RSA 411-A:12, no such health service corporation may acquire and hold directly or indirectly through its subsidiaries or affiliates more than 10 percent of the outstanding voting stock of any life insurance company formed under the laws of this or another state or any corporation owning or holding the stock of such life insurance company.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:19

420-A:19 Prohibiting Limitations on Liability; Disclosure of Information. –
I. No contract between a health service corporation and a physician, for the purpose of delineating the rights and obligations of the parties within the provider network, shall limit the liability of the health service corporation for any actions of the physician for which the health service corporation might otherwise be liable.
II. No contract between a health service corporation and a health care provider shall limit what information such health care provider may disclose to patients or to prospective patients regarding the provisions, terms, or requirements of the health service corporation's products as they relate to the needs of such provider's patients except for trade secrets of significant competitive value.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:20

420-A:20 Reports and Examinations. – Every health service corporation shall annually, on or before March 1, file in the office of the commissioner a statement, verified by at least 2 of its principal officers, showing its condition on the preceding December 31, which shall be in such form and contain such matters as the commissioner may prescribe. Examination of the financial condition of each health service corporation by the commissioner shall be made as often as the commissioner deems necessary. The commissioner or designee shall have the power of visitation and examination into the affairs of any health service corporation and free access to all of the books, papers, and documents that relate to the business of the corporation, and may summon and qualify witnesses under oath and examine its officers, agents, or employees or other persons in relation to the affairs, transactions, and condition of the corporation. All costs of such examination shall be paid by the health service corporation.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:21

420-A:21 Reserves. – Every health service corporation shall collect reasonable rates as described in RSA 420-A:22, designed to permit it to accumulate and maintain a contingency reserve fund.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:22

420-A:22 Annual Review. – Annually, in the month of April, the commissioner may review the rates of every health service corporation, and shall, not later than 60 days after April 1 of each year, provided that the corporation has filed all pertinent data, make adjustments thereto, if any, as are just and reasonable. Whenever the contingency reserve fund of a health service corporation shall be less than 8 percent of its annual premium income, the commissioner shall permit the corporation to charge rates designed to enable it to increase its contingency reserve fund by an amount equal to at least 2 percent of the annual premium income of the corporation. If the liabilities of a health service corporation exceed its assets, however, the commissioner shall permit the corporation to charge rates designed to enable the corporation to accumulate such a reserve fund by an amount equal to at least 5 percent of the annual premium income of the corporation until such time as the assets of the corporation equal its liabilities. In no event shall the commissioner permit a health service corporation to charge rates which would result in a reserve fund in excess of 20 percent of the annual premium volume of the corporation. This section shall not preclude the granting of appropriate rate changes at any other times. In connection with a rate decision, the commissioner may also make reasonable supplemental orders to the health service corporation and may attach reasonable conditions and limitations to such orders as the commissioner finds, on the basis of competent and substantial evidence, necessary to insure that benefits and services are provided at minimum cost under efficient and economical management of the corporation.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:23

420-A:23 Appeals. – All orders and decisions of the commissioner concerning matters within the commissioner's jurisdiction under this chapter shall be subject to rehearing and appeal as provided in RSA 541. RSA 541:18 and RSA 541:19 shall apply to orders and decisions of the insurance commissioner affecting the rates of health service corporations.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:24

420-A:24 Agreements With Providers. – Any health service corporation may enter into agreements with eligible persons whereby such persons become providers of a plan operated by the corporation. Any health service corporation may enter into contracts for the payment of health services to the subscribers or members of similar nonprofit health service corporations of other states subject to the supervision of such other states, or of counties of this state in which the corporation does not transact business. The corporation shall maintain in its office complete records of all health services rendered to subscribers and covered dependents in such form as will include the kind of services rendered, the amounts claimed for such services by the providers and the amount paid by the corporation.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:25

420-A:25 Administrative Services. – Any health service corporation may contract to furnish administrative services to any health-related organization, agency, entity, or plan.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:26

420-A:26 Nonliability of Corporation. – No health service corporation holding a license under this chapter shall be liable for injuries resulting from negligence, malfeasance, nonfeasance, or malpractice on the part of any officer or employee or on the part of any provider in the course of rendering health care service or supplies to subscribers.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:27

420-A:27 Taxation. – Except as otherwise expressly provided for by law, every health service corporation doing business pursuant to this chapter is hereby declared to be a nonprofit and benevolent organization and to be exempt from all taxes, other than taxes on real property situated within this state, fees on motor vehicles registered in this state, fees prescribed by this chapter, and the premium tax under RSA 400-A:32. Except for payments made by the state of New Hampshire no tax shall be levied on any premiums, fees-for-service and other payments for health, dental, and employee benefit coverages from political subdivisions of the state of New Hampshire, or from employees or retirees of such political subdivisions, either directly or indirectly. Nor shall any tax be levied on any revenues of such a health service corporation that are derived from any business of the corporation where the corporation has assumed no insurance risk and is providing administrative services only.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:28

420-A:28 Relationship of Provider and Patient. – Nothing in this chapter shall be deemed to alter the relationship of physician and patient. No health service corporation shall in any way influence the subscriber in the free choice of hospital or physician or other provider. Nothing in this chapter shall be deemed to abridge the right of any hospital, physician or other provider to decline patients in accordance with lawful standards and practices of such provider.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:29

420-A:29 Foreign Corporations; Reciprocity. – Any corporation organized under the laws of another state or country which except as to state of organization is a health service corporation and which the commissioner finds has fully complied with the laws of such other state or country, shall be entitled to do business within this state subject to this chapter after obtaining a license as provided in RSA 420-A:4; provided, however, that no such corporation organized under the laws of another state or country shall be entitled to such license, or to do business in this state, unless such other state or country grants substantially similar rights and privileges to health service corporations organized under the laws of this state. The commissioner shall determine whether rights and privileges granted by other states or countries are substantially similar to those granted by this state, and the commissioner's determination shall be final.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:30

420-A:30 Exceptions. – Fraternal benefit societies and life or accident insurance companies are not affected by this chapter.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:31

420-A:31 Rules. – The commissioner is authorized and empowered to adopt such rules in accordance with RSA 541-A which are reasonable and necessary to administer and enforce the provisions of this chapter.

Source. 1997, 190:1, eff. Jan. 1, 1998.

Section 420-A:32

420-A:32 Workers' Compensation Law Not Affected. – No provision of this chapter or any contract for hospital service by such health service corporation shall in any way affect the operation of workers' compensation laws of the state.

Source. 1997, 190:1, eff. Jan. 1, 1998.