New Hampshire Law Reimbursement
Re: Insurance Parity
415:5 Form of Policy. –
I. No policy of accident and sickness insurance shall be delivered or issued for delivery to any person in this state unless:
(1) The entire money and other considerations therefor are expressed therein; and
(2) The time at which the insurance takes effect and terminates is expressed therein; and
(3)(a) It purports to insure only one person, except that a policy may, at the election of the carrier, insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any 2 or more eligible members of that family, including husband, wife, dependent children, or any other person dependent on the policyholder. In the event a carrier elects to provide coverage for dependent children, the term "dependent child'' shall include a subscriber's child by blood or by law, who is under age 26.
(b) Nothing in this subparagraph shall be construed to require:
(1) Coverage for services provided to a dependent before the effective date of this section; or
(2) That an employer pay all or part of the cost of family coverage that includes a dependent as provided pursuant to this subparagraph.
(c) A subscriber that elects family coverage during any applicable open enrollment period may enroll any dependent eligible pursuant to this subparagraph.
(d) Coverage for a dependent provided pursuant to this subparagraph shall be provided until the earlier of the following:
(1) The dependent is disqualified for dependent status as set forth in subparagraph I(3)(a); or
(2) The date upon which the employer under whose contract coverage is provided to a dependent ceases to provide coverage to the subscriber.
(e) Nothing in this subparagraph shall be construed to permit a health insurance carrier to refuse an election for coverage by a dependent pursuant to subparagraph (c), based upon the dependent's prior disqualification pursuant to subparagraph (d)(1).
(f) Notice regarding coverage for a dependent as provided pursuant to this subparagraph shall be provided to a subscriber:
(1) In the certificate of coverage prepared for subscribers on or about the date of commencement of coverage; and
(2) Within 30 days following the effective date of this subparagraph. Such notice shall include information regarding the required special open enrollment period.
(3-a)(a) The coverage of any family member insured by such policy, pursuant to subparagraph (3), who is mentally or physically incapable of earning his or her own living on the date as of which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another policy as long as such incapacity continues and as long as said dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of said dependent, provided that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this subparagraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G;
(b) If the coverage for dependent children under subparagraph (3) includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this subparagraph. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this subparagraph. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this subparagraph commences; and
(4) The style, arrangement and over-all appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any indorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point (the "text'' shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and
(5) The exceptions and reductions of indemnity are set forth in the policy, and, except those which are set forth in RSA 415:6, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as "Exceptions,'' or "Exceptions and Reductions,'' provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and
(6) Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and
(7) It contains no provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the commissioner; and
(8) Wherever such policy provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of osteopathy, chiropractic, podiatry, optometry, or licensed as an advanced practice registered nurse, said policy contains a provision for reimbursement for such service when performed by a person so licensed.
(9) Notwithstanding any provisions in any such policy or contract for the provision of health care services or benefits provided by any health, medical or other service corporation licensed by the state, whenever the terms "physician'' or "doctor'' are used in any such policy or contract, said terms shall include within their meaning those persons licensed under RSA 317-A in respect to any care, services, procedures or benefits covered by said policy or contract which the persons so licensed are authorized to perform.
(10) It also conforms to the relevant provisions of RSA 420-G.
II. If any policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the commissioner that any such policy is not subject to approval or disapproval by such official, the commissioner may by ruling require that such policy meet the standards set forth in paragraph I of this section and in RSA 415:6.
III. Nonrenewable, individual health insurance policies which provide medical, hospital, or major medical expense benefits for a specified term may be delivered or issued for delivery to any person in this state for purposes of providing short-term, interim coverage only and no such policy shall provide coverage for a specified term in excess of 6 months, nor shall any such policy be issued in this state to a person who was previously covered under short-term medical policies providing in total more than 540 days of coverage within the preceding 24-month period.
Source. 1913, 226:2. PL 281:4. RL 331:4. 1951, 207:1, par. 4. RSA 415:5. 1969, 163:2; 271:1. 1973, 72:71. 1975, 111:1. 1985, 239:1. 1995, 112:5. 1997, 344:2. 2001, 112:1, eff. Aug. 25, 2001. 2006, 321:2, eff. June 22, 2006. 2007, 352:1, eff. Sept. 15, 2007. 2009, 54:5, eff. July 21, 2009; 177:1, eff. Sept. 11, 2009; 235:1, 2, eff. Sept. 14, 2009. 2010, 243:8, eff. Sept. 23, 2010.
415:18 General Group or Blanket Policy Provisions. –
I. Policies, certificates and other forms attached to group or blanket accident or health insurance, or accident and health insurance, shall comply with all applicable laws, including RSA 420-G, and with rules adopted by the commissioner. No such policy or certificate shall be delivered or issued for delivery in this state to a resident of this state without the prior written approval of the commissioner. The commissioner shall adopt rules, pursuant to RSA 541-A, establishing conditions by which insurers may deem such policies or certificate forms approved upon the expiration of a 30-day period following the commissioner's receipt of the insurer's submission of the policy and certificate forms for approval. No policy of group or blanket accident or health insurance, or accident and health insurance affecting a resident of New Hampshire, whether such policy is delivered or issued for delivery in this state or any other state, and no certificate thereunder shall, except as provided in paragraph III of this section, be delivered or issued for delivery in this state unless the policy or certificate contains in substance each and all of the provisions set forth in the following subparagraphs or provisions which in the opinion of the commissioner are more favorable to the holders of such certificates or not less favorable to the holders of such certificates and more favorable to policyholders:
(a) A provision that no statement made by the applicant for insurance shall avoid the insurance or reduce benefits thereunder unless contained in the written application signed by the applicant; and a provision that no agent has authority to change the policy or to waive any of its provisions; and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer.
(b) A provision that all statements contained in any such application for insurance shall be deemed representations and not warranties.
(c) A provision that all new employees or new members, as the case may be, in the groups or classes eligible for such insurance must be added to such groups or classes for which they are respectively eligible.
(d) A provision that all premiums due under the policy shall be remitted by the employer or employers of the persons insured or by some other designated person acting on behalf of the association or group insured, to the insurer on or before the due date thereof, with such grace period as may be specified therein.
(e) A provision stating the conditions under which the insurer may decline to renew the policy.
(f) A provision that the insurer shall issue to the employer or other person or association in whose name such policy is issued, for delivery to each member of the insured group, an individual certificate setting forth in summary form a statement of the essential features of the insurance coverage of such employee or such member, to whom the benefits thereunder are payable, and in substance the provisions of subparagraphs (g) to (s) inclusive.
(g) A provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages.
(h) A provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.
(i) A provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within one year after the date of such loss in the case of a group Medicare supplement insurance policy or certificate and within 90 days after the date of such loss in the case of any other group accident and health insurance policy or certificate. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.
(j) A provision that the insurer will furnish to the policyholder such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished before the expiration of 15 days after the insurer receives notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made.
(k) A provision that the insurer shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.
(l) A provision that all benefits payable under the policy other than benefits for loss of time will be payable not more than 60 days after receipt of proof, and that, subject to due proof of loss all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.
(m) A provision that indemnity for loss of life of the insured is payable to the beneficiary if surviving the insured, and otherwise to the estate of the insured; and that all other indemnities of the policy are payable to the insured, except as provided in paragraph IV of this section; and that if a beneficiary is designated, the consent of the beneficiary shall not be requisite to change of beneficiary, or to any other changes in the policy or certificate, except as may be specifically provided by the policy.
(n) A provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within 2 years from the expiration of the time within which proof of loss is required by the policy.
(o) A provision that if loss of time benefits payable to the holder of the certificate are reduced by reason of benefits payable to the holder of the certificate under the federal Social Security Act, such benefits shall not be further reduced by reason of any increase in benefits payable under the federal Social Security Act which takes effect after the first month that benefits are payable for a period of disability; except that if benefits under the policy are provided on a specified dollar amount basis, then such benefits shall not be further reduced by reason of any increase in benefits payable under the federal Social Security Act which takes effect after the effective date of the policy.
(p) A provision that the policyholder is entitled to a grace period of 31 days for the payment of any premium due except the first, during which grace period the coverage shall continue in force, unless the policyholder has given the insurer written notice of discontinuance in advance of the period for which payment is due, and in accordance with the terms of the policy. The policy may provide that the policyholder shall be liable to the insurer for the payment of a portion of the premium corresponding to the time within the grace period during which the policy was in force.
(q) A provision that the insurer shall not exclude part-time employees and shall offer the same group health benefits to part-time employees as it offers to the employee groups of which the part-time employees would be members if they were full-time employees. The insurer shall offer to include the part-time employees as part of the employer's employee group, at the full rate to be paid by the employer, at a rate prorated between the employer and the employee, or at the employee's expense. A part-time employee shall be any employee who regularly works at least half of the weekly hours of the full-time employee in the employee group of which the part-time employee would be a member if he were a full-time employee, but who works a minimum of at least 15 hours per week. An insurer, however, may exclude part-time employees from eligibility for group health coverages providing disability or income replacement benefits, whether short- or long-term.
(r) A provision that the validity of the policy shall not be contested except for nonpayment of premiums, after it has been in force for 2 years from its date of issue; and that no statement made by any person covered under the policy relating to insurability shall be used in contesting the validity of the insurance with respect to which such statement was made after such insurance has been in force prior to the contest for a period of 2 years during such person's lifetime, nor unless it is contained in a written instrument signed by the person making such statement. No such provision, however, shall preclude the assertion, at any time, of defenses based upon the person's ineligibility for coverage under the policy or upon other provisions in the policy, except for any provisions establishing, as a requirement of eligibility, the furnishing of satisfactory evidence of insurability to the insurer.
(s) [Repealed.]
(t) A provisions as follows: Payment of Claims. Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured. (The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:
(1) If any indemnity of this policy or certificate shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $ (insert an amount which shall not exceed $1,000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.
(2) Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy or certificate on account of hospital, nursing, medical, or surgical services may, at the insurer's option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.)
(u) A provision that in the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.
I-a. "Blanket accident and health insurance'' means that form of accident and health insurance that is not "health coverage'' under RSA 420-G:2, IX, that does not require individual applications from covered persons, and that does not require a carrier to furnish each person with a certificate of coverage. Blanket health coverage shall be issued only to the following groups and cover only the following defined persons in the groups:
(a) A common carrier, which shall be deemed the policyholder, and which shall cover a group defined as all or any of the class of persons who may become passengers on such a common carrier.
(b) An employer, which shall be deemed the policyholder, and which shall cover all employees or any subset of employees defined solely by reference to exceptional hazards incident to such employment.
(c) A volunteer fire department, first aid, or other such volunteer group, which shall be deemed the policyholder, and which shall cover all the members of such department or group.
(d) A sports team or a camp, which team or camp shall be deemed the policyholder and which shall cover all members or campers.
(e) A travel agency, or other organization that provides travel-related services, which organization shall be deemed the policyholder and which shall cover all persons for whom travel-related services are provided. Notwithstanding anything herein to the contrary, blanket accident and health coverage for travel-related services issued to a travel agency or to an organization that provides travel-related services may require individual applications or enrollment forms from covered persons and premium payments from covered persons, and the carrier may furnish each covered person with a summary of benefits.
I-b. The benefits payable under blanket accident and health insurance shall not be assigned to a health care provider.
II. Any portion of any policy of group or blanket accident or health insurance affecting a resident of New Hampshire, whether such policy is delivered in this state or any other state, and any certificate under such policy, which purports, by reason of the circumstances under which a loss is incurred, to reduce any benefits promised thereunder to an amount less than that provided for the same loss occurring under ordinary circumstances, shall be printed, in such policy and in each certificate issued under such policy, in boldface type and with greater prominence than any other portion of the text of such policy or certificate, respectively; and all other exceptions of the policy shall be printed in the policy and in the certificate, with the same prominence as the benefits to which they apply.
III. The commissioner may approve any form of blanket accident or health or accident and health insurance policy, or any form of certificate to be issued under such policy, which omits or modifies any of the provisions hereinbefore required, if he deems such omission or modification suitable for the character of such insurance and not unjust to the persons insured thereunder.
IV. Any such group policy may include benefits payable on account of hospital or medical or surgical aid for an employee or other member of the group insured by such policy, his or her spouse, child or children or other dependents, and may provide that any such benefits be paid by the insurer directly to the hospital, physician, surgeon, doctor, nurse or other person furnishing services covered by such provision of said policy.
IV-a. [Repealed.]
V. (a) The coverage of any dependent of any employee or member of the group insured by such policy, pursuant to paragraph IV, who is mentally or physically incapable of earning his or her own living on the date as of which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another group policy as long as such incapacity continues and as long as said dependent remains chiefly financially dependent on the employee or member of the group or the employee or his or her estate is chargeable for the care of said dependent, provided that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this paragraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G.
(b) If the coverage for dependent children under paragraph IV includes coverage for dependent children who are full-time students, as defined by the appropriate educational institution, beyond the age of 18, such dependent coverage shall include coverage for a dependent's medically necessary leave of absence from school for a period not to exceed 12 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy, whichever comes first. Any breaks in the school semester shall not disqualify the dependent child from coverage under this subparagraph. Documentation and certification of the medical necessity of a leave of absence shall be submitted to the insurer by the student's attending physician and shall be considered prima facie evidence of entitlement to coverage under this subparagraph. The date of the documentation and certification of the medical necessity of a leave of absence shall be the date the insurance coverage under this subparagraph commences.
VI. Notwithstanding any provision of any policy of insurance issued under the provisions of this section, whenever such policy provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of osteopathy, chiropractic, podiatry, optometry, or licensed as an advanced practice registered nurse, reimbursement under such policy shall not be denied when such service is rendered by a person so licensed.
VII. (a) If a group policy affecting a resident of New Hampshire is delivered or issued for delivery in this state or any other state, and such policy provides hospital or surgical expense insurance or major medical expense insurance for other than specific diseases, accidents only, or student major medical expense coverage insurance where the policyholder is the school, the policy and any certificate issued under such policy to a New Hampshire resident shall contain a provision to the effect that in case of termination for any reason whatever of coverage, including termination of eligibility for continuation coverage, provided any employee while insured under a group policy issued to his or her employer, if the employee or member is not then covered by another policy of hospital or surgical expense insurance or hospital service or medical expense indemnity corporation subscriber contract providing similar benefits or if the employee or member is not covered by or eligible to be covered by a group contract or policy providing similar benefits or is not provided with similar benefits required by any statute or provided by any welfare plan or program, the employee or member, if he or she has been insured under the group policy for at least 60 days, shall be entitled to have issued to him or her by the New Hampshire high risk pool without evidence of insurability upon application to the New Hampshire high risk pool within 31 days after such termination and upon payment of the applicable premium, an individual policy of insurance under RSA 404-G or shall be entitled to elect the 39-week extension period pursuant to RSA 415:18, XVII.
(b) The effective date of the individual policy shall be the date of the termination of the individual's insurance under the group policy. The individual policy shall not exclude any other preexisting condition.
(c) The option to obtain coverage from the New Hampshire high risk pool under RSA 404-G shall also be available, upon the death of the employee or member, to the surviving spouse with respect to those family members who are then covered by the group policy, to a child solely with respect to himself or herself upon his or her attaining the limiting age of coverage under the group policy while covered as a dependent thereunder, and to a former dependent spouse upon remarriage of the group plan member. The option to obtain coverage from the New Hampshire high risk pool shall be exercised within 31 days of the qualifying event.
(d) Each certificate holder in the insured group shall be given written notice of the option and its duration within 30 days after the date of termination of the group contract or policy. Such notice shall be mailed by the insurer to the certificate holder at the last address furnished to the insurer by the contract holder at the same time as the notice required by RSA 415:18, XVII is mailed. Each certificate holder shall have the option of electing an individual policy from the New Hampshire high risk pool under RSA 404-G, or the 39-week extension period provided pursuant to RSA 415:18, XVII. The election of the 39-week extension period upon termination by any person or member shall not preclude such person or member from electing to exercise the option of obtaining coverage from the New Hampshire high risk pool under RSA 404-G at the expiration of the 39-week extension period.
VII-a. Any employee whose compensation includes group hospital or surgical expense insurance or major medical expense insurance for other than specific diseases or accidents only the premiums for which are paid in full or in part by an employer including the state of New Hampshire, its political subdivisions, or municipal corporations, or paid by payroll deduction, may pay the premiums as they become due directly to the policyholder whenever the employee's compensation is suspended or terminated directly or indirectly as the result of a strike, lockout, or other labor dispute for a period not exceeding 6 months and at the rate and coverages as the policy provides.
(a) During said 6-month period, the policy may not be altered or changed, except that nothing in this section shall be deemed to impair the right of the insurer to make normal decreases or increases of the premium rate upon expiration and renewal of the policy, in accordance with the provisions of the policy.
(b) When the employee's compensation is so suspended or terminated, the employee shall be notified immediately by the policyholder in writing, by mail addressed to the address last on record with the policyholder, that the employee may pay the premiums to the policyholder as they become due as provided in this section.
(c) The policyholder shall remit any premiums paid by the employees on a timely basis to the insurer.
(d) Nothing herein shall be deemed to require the continuation of any such group coverage to any individual employee beyond the time that he takes full-time employment with another employer; nor shall anything herein be deemed to require continuation of the group coverage more than 6 months after compensation is suspended or terminated as the result of a labor dispute, nor to require the insurer to continue coverage as to any employee for whose coverage premiums have not been remitted in accordance with the provisions of the policy.
(e) After the 6-month period, the employee shall have the right to continue the benefits being continued under this paragraph for an additional 12 months as if the employee originally had elected the extension period provided by RSA 415:18, XVI and subject to the same conditions. At the end of the additional 12 months, the employee shall have the right, if the group insurance coverage is no longer available, to obtain coverage from the high risk pool.
(f) The provisions of this paragraph shall apply to group hospital and medical expense policies subject to RSA 415 and group health service plan contracts issued pursuant to RSA 420-A, and to health maintenance organization policies and plans issued pursuant to RSA 420-B.
VII-b. Any group accident and health insurance policy covering a resident of New Hampshire shall contain the following provisions:
(a) Upon a final decree of divorce or legal separation, if one spouse is a member of a group accident and health insurance policy, the former spouse who is a family member or eligible dependent under said policy prior to the date of the decree shall be and remain eligible for group benefits as a family member or eligible dependent under said policy, without additional premium or examination, as if said decree had not been issued. Such eligibility shall not be required if the decree expressly provides otherwise.
(b) The former spouse shall be eligible for coverage pursuant to this section through the member's participation in a group accident and health insurance policy, while such policy remains in force or is replaced by another group policy covering the member, until the earliest of the following events occurs:
(1) The 3-year anniversary of the final decree of divorce or legal separation;
(2) The remarriage of the former spouse;
(3) The remarriage of the member;
(4) The death of the member; or
(5) Such earlier time as provided by the final decree of divorce or legal separation.
(c) Upon the occurrence of the earliest of the events set forth in subparagraph (b), other than remarriage of the former spouse, the former spouse shall have the right to continuation coverage under RSA 415:18, XVI. An insurance carrier may charge a premium for the former spouse's continuation coverage under this subparagraph, in accordance with RSA 415:18, XVI. The former spouse shall request enrollment under RSA 415:18, XVI, in writing, within 30 days after the first occurring of the events set forth in subparagraph (b), provided that the former spouse may not request enrollment upon remarriage of the former spouse. If the first occurring event is the member's remarriage or death, the former spouse may request enrollment under RSA 415:18, XVI, in writing, within 30 days after receiving notice of said event.
(d) In the event of the former spouse's remarriage, the former spouse shall notify the insurance carrier, in writing, within 30 days after the date of remarriage, and the effective date of termination of the former spouse's eligibility pursuant to this section shall be the date of remarriage.
(e) The member or former spouse shall submit to the insurance carrier evidence of the former spouse's eligibility under this section within 30 days after the final decree of divorce or legal separation. If the group accident and health insurance policy existing as of the date of the decree is replaced by another group policy covering the member that is issued by a different insurance carrier, said carrier may request that the member or former spouse submit evidence of the former spouse's eligibility under this section within 30 days of the effective date of the member's coverage under the replacement policy. A former spouse's coverage under the member's group accident and health insurance policy pursuant to this section shall be effective as of the date of the final decree of divorce or legal separation in the case of a then existing policy, or, in the case of a replacement policy, the effective date of the member's coverage under such policy.
(f) The former spouse shall notify the insurance carrier, in writing, of any address other than the member's address to which notices and correspondence pertaining to the former spouse's coverage should be mailed, including but not limited to notice of cancellation and any right to reinstate coverage, and the carrier shall use such address until it receives written notice from the former spouse of a change.
(g) Upon termination of the eligibility of a former spouse for group coverage pursuant to this section, said former spouse may apply for individual coverage or the high risk pool, whichever is applicable.
(h) Eligibility of a former spouse for group coverage pursuant to this section exists independent of any right to continuation of coverage under RSA 415:18, XVI. To the extent that there is a conflict between this paragraph and RSA 415:18, XVI with respect to eligibility for group coverage upon a final decree of nullity, divorce or legal separation, the provisions that confer greater rights on the former spouse shall apply unless the decree expressly provides otherwise.
VIII. Notwithstanding any provision of any policy of insurance issued under the provisions of this section, whenever the terms "physician'' or "doctor'' are used in any such policy, said terms shall include within their meaning those persons licensed under RSA 317-A in respect to any care, services, procedures or benefits covered by said policy which the persons so licensed are authorized to perform.
IX. [Repealed.]
X. [Repealed.]
XI. [Repealed.]
XII. No insurer shall, when issuing or renewing a group policy or contract of hospital or surgical expense or major medical expense insurance or any certificate under such policy or contract covered by this chapter, deny coverage or limit coverage to any resident of this state and who is principally employed in this state and to any other person who is a non-resident but who is principally employed in this state on the basis of health risk or condition except that a waiting period consistent with insurance department rules may be imposed for pre-existing medical conditions. If an insurer accepts an application for group hospital or surgical expense or major medical expense coverage, such acceptance shall be subject to the following:
(a) If the group has coverage in effect through another plan, the insurer shall accept all persons covered under the existing plan. If the group does not have coverage in effect through another plan, the insurer shall accept all persons for which the group seeks coverage.
(b) Once a group policy has been issued, any person becoming eligible for coverage shall become covered by enrolling within 31 days after first becoming eligible. Any person so enrolling shall not be required to submit evidence of insurability based on medical conditions. If a person does not enroll at this time, he is a late enrollee.
(c) Once a group policy has been issued, the insurer shall provide the group with an annual open enrollment period for late enrollees. During the open enrollment period, any late enrollee shall be permitted to enroll without submitting any evidence of insurability based on medical conditions. For late enrollees in a large employer group only, the pre-existing condition provisions shall apply for 18 months from the date of enrollment. However, an eligible employee or dependent shall not be considered a late enrollee if the individual:
(1) Was covered under a public or private health insurance or other health benefit arrangement at the time the individual was eligible to enroll; and
(2) Has lost coverage under a public or private health insurance or other health benefit arrangement as a result of termination of employment or eligibility, the termination of the other plan's coverage, death of a spouse, or divorce; and
(3) Requests enrollment within 60 days after termination of coverage provided under a public or private health insurance or other health benefit arrangement; or
(i) The individual is employed by an employer which offers multiple health benefit plans and the individual elects a different plan during an open enrollment period; or
(ii) A court has ordered coverage to be provided for an ex-spouse or minor child under a covered employee's health benefit plan and request for enrollment is made within 30 days after issuance of such court order.
XIII. An insurer issuing policies of group insurance shall allocate the costs associated with maternity and childbirth over both males and females covered by its entire block of business in this state. In cases in which, because of the amount written in the state, allocation to an entire block of business needs to occur, the carrier may apply for a waiver from the insurance commissioner.
XIV. An insurer issuing policies of group insurance shall provide to each new certificate holder who is a resident of this state a copy of the patients' bill of rights law under RSA 151:21.
XV. In paragraphs XVI and XVII:
(a) "Carrier'' means an entity that offers or provides a policy, contract, or certificate of insurance coverage in this state. "Carrier'' shall include an insurer, a health maintenance organization, or any other entity providing a policy, contract, or certificate of insurance coverage subject to state insurance regulation.
(b) "Cancellation'' means the circumstance when the employer/employee relationship ceases to exist.
(c) "Individual'' means any person covered under a group health plan, including but not limited to, the covered employee, the spouse of the covered employee, whether surviving, dependent, former dependent, divorced or legally separated; or the dependent child of the employee, and any other person including a child born or placed for adoption with the covered employee, who is covered under a group health plan through the employment relationship.
(d) "Health insurance'' means all group hospital and medical expense policies subject to RSA 415, group health service plan contracts pursuant to RSA 420-A, and health maintenance organization policies and plans issued pursuant to RSA 420-B, and all other plans that are additionally subject to RSA 420-G, except for small employers of size one defined pursuant to RSA 420-G:2, XVI.
(e) "Entire group termination'' means that circumstance when all health insurance coverage to the group ends.
XVI. Continuation of Coverage.
(a) Carriers shall provide continuation of coverage when an individual covered by a plan of group health insurance or a health maintenance organization that provides medical, hospital, dental, and/or surgical expense benefits, except student major medical expense coverage where the policyholder is the school, loses coverage under the plan. Any group policy of health insurance that affects a resident of New Hampshire that is delivered or issued for delivery in this state or any other state shall contain a provision that allows each subscriber or member on the policy who is a resident of New Hampshire to obtain continuation coverage under this section. Coverage shall be provided in accordance with the procedures described in this section.
(b) Continuation coverage shall be identical to the coverage provided to other similarly situated members of the group that are still covered by the plan. The policy shall not be changed from the underlying group coverage, except that normal premium rate increases or decreases upon renewal affecting the group plan may also affect the continuation premium rate. The effective date of continuation coverage shall be the date the individual's coverage under the group plan ceased.
(c) Periods of coverage shall be as follows:
(1) Eighteen month period--When any individual loses coverage under a group health insurance plan for any reason except dismissal from employment for gross misconduct or carrier termination, coverage shall continue subject to this section for a period of 18 months, unless the individual is eligible for coverage under subparagraphs (2), (3), (4), or (5).
(2) Thirty-nine week period (entire group insurance termination)--Whenever the entire group is terminated, coverage shall continue subject to this section for a period of 39 weeks. Where an individual has continuation coverage, coverage shall continue until it would have expired had the plan not been terminated or for 39 weeks, whichever occurs first.
(3) Twenty-nine month period (disability)--An individual who is determined to be disabled within the first 60 days of the date such individual loses coverage shall be entitled to 29 months of continuation coverage. Determination of disability shall be under Title II or XVI of the federal Social Security Act or any future act that has the same purpose.
(4) Thirty-six month period--Subject to subparagraph (e), coverage shall continue subject to this section for a period of 36 months if any individual loses coverage under a group health insurance plan for one of the following reasons:
(A) Death of a covered employee;
(B) The divorce or the legal separation of the covered employee or, if the employee's former spouse has been covered pursuant to RSA 415:18, VII-b, the first occurring of any of the following events:
(i) The remarriage of the covered employee;
(ii) The death of the covered employee;
(iii) The 3-year anniversary of the final decree of divorce or legal separation; or
(iv) Such earlier time as provided by said decree;
(C) A substantial loss of coverage by retirees and dependents within one year of the employer filing for protection under the bankruptcy provisions of Title 11 of the United States Code; or
(D) A dependent child ceasing to be a dependent child.
(5) When the surviving spouse, divorced spouse, or legally separated spouse is 55 years of age or older and loses coverage because of the death, divorce, or legal separation of the covered employee, coverage shall continue subject to this section until such time as the spouse becomes eligible for participation in another employer-based group plan or becomes eligible for Medicare.
(d) Premium Payments. When an individual's coverage has ended, the amount of the premium charged to the individual electing continuation coverage shall not exceed 102 percent of the group premium amount as allocated for that individual's coverage.
(e) Responsibilities.
(1) When an individual loses coverage, it shall be the responsibility of the carrier to notify the individual of the right to elect continuation coverage.
(2) It shall be the responsibility of the individual electing continuation coverage to make timely premium payments. A 30-day grace period for payment of the premium shall be provided. Failure to make a timely remittance of the premium shall be grounds for cancellation. Whenever a carrier fails to notify an individual that his or her coverage will not continue unless the individual so elects, the carrier shall be liable, in accordance with the terms of the policy, for claims accrued until such notice is made, except that any carrier that in good faith mailed a notice to the last known address of the individual shall not be held liable. Such carrier's liability shall in no way diminish the liability of the employer if the employer fails to notify the carrier of a member's loss of coverage.
(f) Notice Requirements and Procedures. A carrier shall notify the members and subscribers of their continuation rights as follows:
(1) The carrier shall provide, at the time of commencement of coverage under the health benefit plan, a summary plan description to each eligible member or subscriber of the rights provided under this section.
(2) Notice of the right to continue coverage also shall be set forth in each master policy and individual certificate of coverage.
(3) When coverage for an individual will cease under the group policy, the carrier shall notify the individual of the individual's right to continue, the amount of the premium required to continue coverage, and the procedure for electing continuation coverage. The notice of continuation shall specify the election period that shall not be less than 45 days after the date of the notice and shall be mailed to the last known address of the individual provided by the employer or plan administrator.
(4) The carrier shall specify in each notice of continuation how premium payments are to be remitted.
(5) The carrier shall notify the individual of the right to continue coverage within 30 days of receiving notice from the plan administrator or employer of the loss of coverage.
(g) Election Requirements and Procedures.
(1) An individual electing continuation coverage shall notify the carrier in writing with a copy of the notice provided to the employer or plan administrator when the election is made. Such election shall be made within 45 days of the date of notice.
(2) Where the employee's spouse is also covered by the group plan, and there is a divorce or legal separation, the employee shall notify the employer of the divorce or separation within 30 days, and shall provide the employer and carrier with the employee's spouse's mailing address. In case of a divorce or legal separation, the carrier shall provide a separate notice of the right to continue to the divorced or separated spouse. The divorced or separated spouse may elect to continue coverage pursuant to this section by notifying the carrier within 45 days of the date of the notice and remitting the premium payment. The notice and election provisions of this paragraph shall also apply if the divorced or legally separated spouse of the employee has been covered pursuant to RSA 415:18, VII-b, upon the occurrence of any of the following events:
(A) The remarriage of the employee;
(B) The death of the employee;
(C) The 3-year anniversary of the final decree of divorce or legal separation; or
(D) Such earlier time as provided by the final decree of divorce or legal separation.
(3) Election by the individual shall be made within the period of time stated in the notice of the right to continue, by written notice to the carrier and the employer. The required premium payment, as specified in the notice of the right to continue, shall be remitted as required in the notice with the written notice of election.
(4) Where an individual declines the right to continue coverage pursuant to this section, waiver shall be made by an affirmative means of declination, including but not limited to written declination of continuation coverage or electronic contact to the employer or plan administrator. An individual shall have the right to revoke the notice of declaration anytime within the specified election period.
(5) Where proper notice has been given, and no response is made within the election period, coverage may be deemed waived if the carrier has in good faith made reasonable efforts to contact the eligible individual. However, no carrier may deem any coverage waived if a notice does not fully comply with this section.
(6) Where an individual has attempted to notify the carrier, employer, or plan administrator of election, and where the written election has not included a premium payment, the carrier shall allow the individual to comply by paying the full amount of the unpaid premiums within 30 days of the date of election.
(7) Where more than one person covered by the group health insurance plan will lose coverage as a result of the covered employee's termination from the group, each individual shall be provided with a notice and shall have the opportunity to elect or waive coverage. Where there is a choice among plans, each individual shall have the opportunity to choose a plan.
(8) An election of continuation of coverage by a subscriber shall be deemed to include an election of continuation coverage on behalf of any other of the subscriber's dependents or beneficiaries who would lose coverage under the health benefit plan.
(h) End of Continuation Coverage. Nothing in this paragraph shall require a carrier to continue coverage pursuant to this section beyond:
(1) The first day of the month following the individual's eligibility for a group plan through a different employer;
(2) In the case of an individual that is eligible for Medicare, the date of the first Medicare open enrollment period following the date the individual became ineligible for continued participation under the group plan;
(3) In the case of a period of extended coverage for a person who has been determined to be disabled during the first 60 days of continuation coverage, the month that begins more than 30 days after the date of a final determination that the person is no longer disabled;
(4) The date on which continuation coverage ceases because the individual has failed to pay the premium. The individual shall be given a 30-day grace period before coverage is cancelled, and shall be provided with a notice within 15 days of the date of termination that the coverage will be cancelled if the premium is not paid; or
(5) The date on which the group plan terminates subject to the continuation rights set forth in RSA 415:18, XVII.
(i) The provisions of this paragraph shall apply to group hospital and medical expense policies subject to RSA 415, group health service plan contracts issued pursuant to RSA 420-A, and to health maintenance organization policies and plans issued pursuant to RSA 420-B, and to group policies that cover New Hampshire residents who work in other states. The provisions of this section shall not apply to individuals covered under group policies issued to small employers of size one, as defined pursuant to RSA 420-G:2, XVI.
(j) Relationship to Federal Law. In any circumstance where more extensive notice requirements or other procedural requirements apply, the health benefit plan shall satisfy the specific requirements of federal law with respect to those procedural requirements.
XVII. Termination of Coverage.
(a) Whenever any group hospital, surgical, dental insurance plan, medical insurance plan, or health maintenance organization coverage terminates for any reason, the benefits of such plan shall be available at the same group rate to the covered members of the group plan, for an extension period of 39 weeks, or until such member of the group plan becomes eligible for benefits under another group plan, whichever occurs first.
(b) Written notice of the right to continue such group coverage upon termination shall be given by the carrier in each master policy, certificate, and group policy.
(c) Upon termination of the group policy for nonpayment of premiums the carrier shall give notice within 30 days of the effective date of termination of the policy to the policyholder and each certificate holder under the policy. Termination of the group policy for nonpayment of premiums shall occur no earlier than the date of expiration of the grace period, pursuant to RSA 415:18, I(p), for which premium was due but not paid. The notice shall provide that the certificate holder or policyholder may elect coverage from the date of termination to the date of notice; or elect coverage from the date of termination to the date of notice and continue such coverage in force pursuant to subparagraphs (d), (e), and (f).
(d) The member electing coverage under this subparagraph shall provide the carrier written notice of election together with the required premium contribution within 31 days of the date of the notice. The group rate shall be paid by the member directly to the carrier. The premium rate shall be that required for the coverage being continued and shall not exceed the applicable group rate, but a reasonable administrative fee not to exceed 2 percent of the monthly premium may be charged to offset billing and payment costs.
(e) If group members become entitled to the 39-week extension period due to termination of the policy, the carrier shall:
(1) Notify such person or member of the option to elect continuation of coverage for the extension period of 39 weeks and the conditions applicable to such coverage within 30 days of the date the plan terminates.
(2) If the carrier fails to notify the members of the termination of the group plan within 30 days of the date of termination of the group coverage, the members shall not be liable for any premiums that have not been paid prior to the date the notice was sent. In no event shall a person or member entitled to coverage for the extension period of 39 weeks be responsible for premiums accrued and unpaid prior to the date of the termination or cancellation of the coverage.
(3) Where coverage has ended as a result of an employer's nonpayment of premiums, the member electing continuation coverage shall not be liable for any accrued and unpaid premium that was the employer's r
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