HB921 (2007) Detail

Making technical changes in the insurance laws.


CHAPTER 289

HB 921-FN – FINAL VERSION

27Mar2007… 0963h

05/10/07 1448s

13Jun2007… 2139eba

2007 SESSION

07-0573

01/10

HOUSE BILL 921-FN

AN ACT making technical changes in the insurance laws.

SPONSORS: Rep. McLeod, Graf 2; Rep. D. Flanders, Belk 4; Rep. Headd, Rock 3; Sen. Sgambati, Dist 4

COMMITTEE: Commerce

ANALYSIS

This bill makes various technical changes to the insurance laws.

This bill is a request of the insurance department.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

27Mar2007… 0963h

05/10/07 1448s

13Jun2007… 2139eba

07-0573

01/10

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Seven

AN ACT making technical changes in the insurance laws.

Be it Enacted by the Senate and House of Representatives in General Court convened:

289:1 New Subparagraph; Accident and Sickness Policy Provisions. Amend RSA 415:6, I by inserting after subparagraph (14) the following new subparagraph:

(15) A provision as follows: Pre-certification: In the event that a person is covered by more than one plan that requires pre-certification, the member shall obtain pre-certification from the primary plan. Although the member shall not be required to obtain pre-certification from the secondary plan, the secondary plan shall not be required to treat such services as covered services if the services do not meet its certification criteria. The secondary plan shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan.

289:2 Accident and Health Insurance; Group or Blanket Provisions. Amend the section heading of RSA 415:18 to read as follows:

415:18 General Group or Blanket Policy Provisions.

289:3 New Subparagraph; Accident and Health Insurance; Group. Amend RSA 415:18, I by inserting after subparagraph (t) the following new subparagraph:

(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.

289:4 Accident and Health Insurance; Group. Amend RSA 415:18, V(a) to read as follows:

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 or blanket 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 [a converted policy in accordance with and subject to the terms and conditions of the conversion privilege clause if such privilege is afforded by the policy, provided that such dependent has not attained the limiting age if any for coverage of adults specified in the policy] coverage offered by the New Hampshire high risk pool under RSA 404-G.

289:5 Accident and Health Insurance; Group. Amend RSA 415:18, VII to read as follows:

VII.(a) If a group or blanket 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 short-term student 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, [or to trustees, or of a termination for any reason whatever of insurance provided any member while insured under a group policy issued to a labor union,] 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 [which together with converted policy would result in over-insurance or duplication of benefits according to standards on file with the commissioner relating to individual policies], 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 [insurer] New Hampshire high risk pool without evidence of insurability upon application [therefor made to the insurer] to the New Hampshire high risk pool within 31 days after such termination and upon payment of the [quarterly] applicable premium, [applicable to the class of risk to which the covered person belongs, to the age of such person, and to the form and amount of insurance, an individual policy of insurance, hereinafter referred to as the converted policy. Subject to the provisions of this paragraph, the benefits provided under the converted policy shall be those required by paragraphs IX, X and XI, whichever is applicable. The commissioner may from time to time make rules to establish minimum standards for such converted plans, according to RSA 541-A.

(b) The plans chosen by the employee or member, shall, at the option of the employee or member, provide identical coverage including maternity at the option of the employee or member for the dependents of such employee or member who were covered under the group policy; provided, however, that in no event shall any of the benefits provided under such plan exceed those provided for such persons under the group policy from which the conversion was made] 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.

[(c)] (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 [but the hospital, surgical or medical benefits paid under the policy may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual’s insurance thereunder, and during the first policy year of such converted policy the benefits payable under the policy may be reduced so that they are not in excess of those that would have been payable had the individual’s insurance under the group policy remained in force and effect; nor shall the individual’s policy contain an age limit, except that the insurer shall not be required to convert a policy or to continue in force a converted policy which provides coverage to an individual eligible for benefits under the federal Social Security Act. The individual converted policy may include a provision whereby the insured may request information at any premium due date of the policy of any person covered thereunder as to whether he is 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 is then covered by a group contract or policy providing similar benefits or is then provided with similar benefits, required by any statute or provided by any welfare plan or program. If any such person is so covered or so provided and fails to furnish the details of such coverage when requested, the benefits payable under the converted policy may be based on the hospital, surgical or medical expenses actually incurred after excluding expenses to the extent they are payable under such other coverage or provided under such statute, plan or program].

[(d) In the event the benefits payable are reduced in accordance with the provisions of this paragraph, the insurer shall return the portion of the premium paid which exceeds the pro rata portion of the benefits thus determined.

(e)] (c) The [conversion provision] 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, [and shall be available] 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[. The conversion provision shall also be available], and to a former dependent spouse upon remarriage of the group plan member. [A former dependent spouse shall exercise the conversion] The option to obtain coverage from the New Hampshire high risk pool shall be exercised within 31 days of the [remarriage of the group plan member] qualifying event.

[(f)] (d) Each certificate holder in the insured group shall be given written notice of [this conversion privilege] the option and its duration within [15] 30 days after the date of termination of the group contract or policy. [If this notice is given more than 15 days after the date of termination, the time allowed for the exercise of the privilege of conversion shall be extended for a period of 15 days following receipt of written notice by the certificate holder.] 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, [VII(g)(4)] XVII is mailed. Each certificate holder shall have the option of electing an individual [conversion] policy from the New Hampshire high risk pool under RSA 404-G, or the 39-week extension period provided pursuant to RSA 415:18, [VII(g)(4)] 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 [a converted policy] 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.

[(g)(1) Whenever any individual who is a member of any group hospital, surgical, medical insurance plan, dental insurance plan, or health maintenance organization, except short-term student insurance where the policyholder is the school, becomes ineligible for continued participation in such plan for any reason including death, except dismissal for gross misconduct, the benefits of such plan shall be available at the same group rate to the individual, the surviving spouse and the dependents covered by the group plan, for an extension period of:

(A) 18 months; or

(B) 29 months in the case of an individual who is determined, under Title II or XVI of the Social Security Act to have been disabled within the first 60 days of the date such individual becomes ineligible for continued participation in the plan; or

(C) Except when the widow, widower, divorced spouse, or legally separated spouse of a covered employee is 55 years of age or older, 36 months in the case of:

(i) the death of the covered employee;

(ii) the divorce or the legal separation of the covered employee from the employee’s spouse;

(iii) the covered employee’s becoming entitled to benefits under Title XVIII of the Social Security Act or the covered employee’s becoming entitled to benefits under Title XVIII of the Social Security Act within the 18-month continuation in subparagraph (g)(1)(A); or

(iv) a dependent child ceasing to be a dependent child.

(D) When the surviving spouse, divorced spouse, or legally separated spouse of a covered employee is 55 years of age or older, in the case of the death of the covered employee; or, the divorce or the legal separation of the covered employee from the employee’s spouse, then the extension period shall continue until the surviving spouse, divorced spouse, or legally separated spouse becomes eligible for participation in another employer-based group plan or becomes eligible for Medicare.

(E) 36 months, for retirees and dependents who have a substantial loss of coverage within one year of the employer filing for protection under the bankruptcy provisions of Title 11 of the United States Code.

(F) Extension coverage need not be provided beyond:

(i) the first day of the month following the date the individual becomes eligible for benefits under another group plan;

(ii) the date of the first Medicare open enrollment period following the date the individual became ineligible for continued participation under the group plan;

(iii) the date on which the group plan terminates subject to RSA 415:18, VII(g)(4); or

(iv) the date on which coverage ceases because of a failure to make timely payment of premium as required; however, the payment of any premium shall be considered to be timely if made within 30 days after the date due or within such longer period as applies to the plan.

(G) The individual, surviving spouse, divorced spouse, legally separated spouse, or dependent shall elect to continue the participation in the group plan according to rules adopted by the commissioner under RSA 541-A. The individual, surviving spouse, or dependent shall be responsible for payment of premiums which may include an administrative fee not to exceed 2 percent of the monthly premium to the employer or policyholder throughout the extension period. Any divorced spouse or legally separated spouse who is responsible for making a portion of or full payment to the employer shall notify the employer and the insurance company, in writing within 30 days of the decree of divorce or separation, that coverage under this subparagraph is requested. Any employee who is responsible for making a portion of or full payment to the employer shall likewise notify the employer and the insurance company, in writing within 30 days of the decree of divorce or separation, that coverage under this subparagraph is requested. The employer shall have the right to terminate coverage for a former dependent spouse who is receiving coverage under this subparagraph if any payment for the coverage is not received from the former dependent spouse within 30 days of the date the premium payments are due. If any payment for the coverage for which the employee is responsible is not received from the employee within 30 days of the date the premium payments are due, the employer shall have the right to terminate coverage for a former dependent spouse; however, no such termination shall occur without 30 days’ prior notice to the former dependent spouse, during which time the former dependent spouse shall be given an opportunity to make the payments due or to secure payment from the employee. Upon termination of the extension period, the member, surviving spouse, divorced spouse, legally separated spouse, or dependent shall be entitled to exercise any option which is provided in the group plan to elect a converted policy. After timely receipt of the premium payment from the individual, surviving spouse, divorced spouse, legally separated spouse, or dependent, if the employer fails to make payments to the insurer or health service corporation or health maintenance organization, with the result that coverage is terminated, the employer shall be liable for benefits to the same extent as the insurer or health service corporation or health maintenance organization would have been liable if coverage had not been terminated.

(2) The provisions of this section 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. 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.

(3) [Repealed.]

(4) Whenever any group hospital, surgical, medical insurance plan, or health maintenance organization coverage terminates for any reason, unless such member, surviving spouse or dependent is, at the termination date, enrolled in the group plan pursuant to RSA 415:18, VII(g)(1), the benefits of such plan shall be available at the same group rate to the individual, the surviving spouse, and the dependents covered by the group plan, for an extension period of 39 weeks, or until such member, surviving spouse, or dependent becomes eligible for benefits under another group plan, whichever occurs first. Any such member, surviving spouse or dependent who is enrolled in the group plan pursuant to RSA 415:18, VII(g)(1) upon the termination date shall have the benefits of such plan available to him at the same group rate for an extension period of 39 weeks, or an extension period to the date the extension provided under RSA 415:18, VII(g)(1) would have expired had the plan not been terminated, or until such member, surviving spouse or dependent becomes eligible for benefits under another group plan, whichever occurs first. Written notice of the right to continue such group coverage shall be given by the insurance company in each master policy, certificate, and group policy. The insurance company shall furnish each employer or group an adequate supply of attachments for each master policy, certificate, or group policy in effect. An individual, surviving spouse, or dependent electing continuation of coverage under this subparagraph shall provide the insurance company written notice of election together with the first monthly premium contribution within 31 days from the date notice of the option to elect continuation of coverage was sent by the insurance company. The group rate shall be paid by the individual, surviving spouse, or dependent directly to the insurance company. 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. Upon termination of the extension period, the member, surviving spouse, or dependent shall be entitled to exercise any option which is or was provided in the group plan to elect a converted policy. If a person or member becomes entitled to the 39-week extension period under this subparagraph the insurance company shall notify such person or member of the option to elect continuation of coverage and the conditions applicable to such coverage. If such person or member has not been given notice of the termination of the group plan within 15 days after the date of termination of the group coverage, then the person or member shall have an additional period within which to elect the 39-week extension period. This additional period shall expire 15 days after the person or member shall have been given said notice, but in no event shall the additional period extend beyond 6 months after the expiration of the original 31-day period. Written notice presented to the person or member or mailed by the insurance company to the last known address of the person or member as furnished by the policyholder shall constitute the giving of notice for the purpose of this subparagraph. If an additional period is allowed the person or member for election of the 39-week extension period as provided in this subparagraph, and if written notice of election accompanied by the first monthly premium and any monthly premiums which may be overdue, if any, is made after the expiration of the original 31-day period, but within the additional period allowed an employee or member in accordance with this subparagraph, the effective date of the extension period shall be the date of termination from the group. In no event shall a person or member entitled to such extension period be responsible for premiums accrued and unpaid prior to the termination or cancellation of the coverage.

(5) If the insurer fails to comply with the applicable employee notification requirements of RSA 415:18, VII(g)(4), then the insurer shall be liable for lost benefits payable under and according to the terms of the group policy or contract to the employee resulting from the termination of the employee’s benefit plan. Such liability extends only for the period of non-compliance beginning on the date notification of the employee was required under RSA 415:18, VII(g)(4) and ending on the date written notice is deposited in the United States mail. Such liability for insurers is secondary to the employer’s liability during this period and becomes primary only after the department of labor advises the insurance commissioner of its determination that the employer is financially unable to pay all or any part of the employee’s lost benefits and failed obligations. Such liability for insurers in no way diminishes the employer’s liability during this or any period.]

289:6 Group Insurance. Amend the introductory paragraph of RSA 415:18, XII(c) to read as follows:

(c) Once a group or blanket 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:

289:7 New Paragraphs; Continuation of Coverage; Termination of Coverage. Amend RSA 415:18 by inserting after paragraph XIV the following new paragraphs:

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, 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 short-term student insurance where the policyholder is the school, loses coverage under the plan. Any group or blanket 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;

(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) Eligible for Medicare – 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 by notifying the carrier within 45 days of the date of the notice and remitting the premium payment.

(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, 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 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 415:26.

(i) The provisions of this paragraph shall apply to group hospital and medical expense policies subject to RSA 415, group health service plan contracts issued pursuant to RSA 420-A, and to health maintenance organization policies and plans issued pursuant to RSA 420-B, and to group policies that cover New Hampshire residents who work in other states. The provisions of this section shall not apply to individuals covered under group policies issued to small employers of size one, as defined pursuant to RSA 420-G:2, XVI.

(j) Relationship to Federal Law. In any circumstance where more extensive notice requirements or other procedural requirements apply, the health benefit plan shall satisfy the specific requirements of federal law with respect to those procedural requirements.

XVII. Termination of Coverage.

(a) Whenever any group hospital, surgical, dental insurance plan, medical insurance plan, or health maintenance organization coverage terminates for any reason, the benefits of such plan shall be available at the same group rate to the covered members of the group plan, for an extension period of 39 weeks, or until such member of the group plan becomes eligible for benefits under another group plan, whichever occurs first.

(b) Written notice of the right to continue such group coverage upon termination shall be given by the carrier in each master policy, certificate, and group policy.

(c) Upon termination of the group policy for nonpayment of premiums the carrier shall give notice within 30 days of the effective date of termination of the policy to the policyholder and each certificate holder under the policy. Termination of the group policy for nonpayment of premiums shall occur no earlier than the date of expiration of the grace period, pursuant to RSA 415:18, I(p), for which premium was due but not paid. The notice shall provide that the certificate holder or policyholder may elect coverage from the date of termination to the date of notice; or elect coverage from the date of termination to the date of notice and continue such coverage in force pursuant to subparagraphs (d), (e), and (f).

(d) The member electing coverage under this subparagraph shall provide the carrier written notice of election together with the required premium contribution within 31 days of the date of the notice. The group rate shall be paid by the member directly to the carrier. The premium rate shall be that required for the coverage being continued and shall not exceed the applicable group rate, but a reasonable administrative fee not to exceed 2 percent of the monthly premium may be charged to offset billing and payment costs.

(e) If group members become entitled to the 39-week extension period due to termination of the policy, the carrier shall:

(1) Notify such person or member of the option to elect continuation of coverage for the extension period of 39 weeks and the conditions applicable to such coverage within 30 days of the date the plan terminates.

(2) If the carrier fails to notify the members of the termination of the group plan within 30 days of the date of termination of the group coverage, the members shall not be liable for any premiums that have not been paid prior to the date the notice was sent. In no event shall a person or member entitled to coverage for the extension period of 39 weeks be responsible for premiums accrued and unpaid prior to the date of the termination or cancellation of the coverage.

(3) Where coverage has ended as a result of an employer’s nonpayment of premiums, the member electing continuation coverage shall not be liable for any accrued and unpaid premium that was the employer’s responsibility under the policy, or any amount previously paid by the person for coverage under the policy that due to the employer’s actions was not paid to the carrier.

289:8 New Paragraph; Definition Added. Amend RSA 415-A:1, I-d to read as follows:

I-d. “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.

I-e. “Employee benefit plan” means employee benefit plans described in section 4(a) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1133 and 1135 and not exempted under section 4(b) of this Act other than those plans, or portions of them, that provide disability benefits.

289:9 Standards for Accident and Health Insurance. Amend RSA 415-A:4-b, V(b) to read as follows:

(b) A carrier or other licensed entity that offers group health plans or employee benefit plans shall file with the commissioner by April 1 of each year, a copy of its current grievance procedures, with all changes from the previous year annotated in the document, and a certificate of compliance [by, April 1 of each year], stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.

289:10 Preexisting Conditions. Amend RSA 415-A:5, I to read as follows:

I. If an insurer or a nonprofit hospital or medical service association elects to use a simplified application form for a policy other than a Medicare supplement policy, with or without a question as to the applicant’s health at the time of application, but without any questions concerning the insured’s health history or medical treatment history, the policy, 9 months after the date of [issuance] enrollment, must cover any loss occurring from any preexisting condition not specifically excluded from coverage by terms of the policy and, except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.

289:11 New Paragraph; Multiple-Employer Welfare Arrangements. Amend RSA 415-E:3 by inserting after paragraph II-a the following new paragraph:

II-b. No arrangement shall extend preexisting condition exclusions beyond a period of 9 consecutive months after the date of enrollment of the person’s health coverage.

289:12 New Paragraph; Health Service Corporations; Definition Added. Amend RSA 420-A:1 by inserting after paragraph II the following new paragraph:

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.

289:13 New Section; Coverage for Dependents. Amend RSA 420-A by inserting after section 15-a the following new section:

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.

289:14 New Paragraph; Health Maintenance Organizations; Definition Added. Amend RSA 420-B:1 by inserting after paragraph II the following new paragraph:

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.

289:15 New Section; Coverage for Dependents. Amend RSA 420-B by inserting after section 8-p the following new section:

420-B:8-q 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.

289:16 New Subparagraph; Prohibited Practices; Health Maintenance Organizations. Amend RSA 420-B:12, I by inserting after subparagraph (c) the following new subparagraph:

(d) 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.

289:17 New Paragraph; Preferred Provider Agreements; Definition Added. Amend RSA 420-C:2 by inserting after paragraph II the following new paragraph:

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.

289:18 New Sections; Coverage for Dependents. Amend RSA 420-C by inserting after section 4 the following new sections:

420-C:4-a 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.

420-C:4-b Pre-certification Requirement. 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.

289:19 New Paragraph; Prohibiting Limitations on Liability. Amend RSA 420-C:5-a by inserting after paragraph III the following new paragraph:

IV. No contract between a health care insurer and a health care provider shall limit coverage for preexisting conditions beyond 9 consecutive months from the date of enrollment.

289:20 New Paragraph; Delta Dental. Amend RSA 420-F:5 by inserting after paragraph VI the following new paragraph:

VII. 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 paragraph. 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 paragraph. 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 paragraph commences.

289:21 New Paragraph; Individual Health Insurance; Definition Added. Amend RSA 420-G:2 by inserting after paragraph III the following new paragraph:

III-a. “Date of enrollment” means the first day of coverage under the plan, or, if there is a waiting period, the first day of the waiting period, which is typically the first day of work.

289:22 Definition Amended. Amend RSA 420-G:2, XIV to read as follows:

XIV. “Preexisting condition” means a condition, whether physical or mental, for which medical advice, diagnosis, care or treatment was recommended or received during the 3 months immediately preceding the [effective] enrollment date of health coverage.

289:23 Preexisting Conditions. Amend RSA 420-G:7, I and II to read as follows:

I. A health carrier providing health coverage to large employers may impose a preexisting condition exclusion period, but only if it is at least as favorable to covered persons as the following:

(a) No preexisting condition exclusion shall extend beyond a period of 9 consecutive months after the [effective] date of enrollment of the person’s health coverage; and

(b) Such preexisting condition exclusion period may only apply to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 3 months immediately preceding the [effective] enrollment date of health coverage.

II. A health carrier providing health coverage to individuals or small employers may impose a preexisting condition exclusion period, but only if it is at least as favorable to covered persons as the following:

(a) No preexisting condition exclusion period shall extend beyond a period of 9 consecutive months after the [effective] date of enrollment of the person’s health coverage.

(b) Such preexisting condition exclusion period may only apply to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was received or recommended during the 3 months immediately preceding the [effective] date of enrollment of the person’s health coverage.

289:24 Requested Information; Date Changes. Amend RSA 420-G:14-a, II-IV to read as follows:

II. The commissioner shall request and health carriers shall supply information and data no later than [April] June 1 of each year sufficient to report on the small employer health insurance market. Such information shall be reported for the market as a whole and by market segment. At the commissioner’s discretion, such information may include, but not be limited to, information relating to premium rates and rating practices, the number of groups and individuals insured, availability of coverage and benefit plans, trend, loss ratios, administration costs, and profitability. The commissioner shall file a report of the information by December 1 of each year with the president of the senate, the speaker of the house of representatives, the chairperson of the house commerce committee, and the chairperson of the senate banks and insurance committee.

III. The commissioner shall request and health carriers shall supply information no later than [April] June 1 of each year sufficient to report on the types of health coverage being purchased by individuals and employers by geographic area. The report shall include specific details regarding the type of coverage, including, but not limited to, co-pays, out-of-pocket maximums, network restrictions, and deductibles.

IV. The commissioner shall file the required reports by [July] September 1 of each year with the senate president, the speaker of the house, the chairperson of the house commerce committee, and the chairperson of the senate insurance committee.

289:25 Explanation of Benefits. Amend RSA 420-H:5, IV to read as follows:

IV. Filings subject to this section shall be accompanied by a certificate [signed by an officer of the insurer] stating that [it] the filing meets the minimum reading ease score on the test used or stating that the score is lower than the minimum required but should be approved in accordance with RSA 420-H:6. To confirm the accuracy of any certification, the commissioner may require the submission of further information to verify the certification in question.

289:26 New Section; Managed Care Law. Amend RSA 420-J by inserting after section 3-a the following new section:

420-J:3-b Pre-certification Requirement. 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.

289:27 Managed Care Law; Grievance Procedures. Amend the paragraph heading and the introductory paragraph of subparagraph (a) of RSA 420-J:5, V to read as follows:

V. Manner and Content of Notification of Determination on Appeal. The carrier or other licensed entity shall provide a claimant with a written determination of the appeal.

(a) [The carrier or other licensed entity shall provide a claimant with a written determination of the appeal that] Where a decision is made to uphold, in whole or in part, the denial of benefits, the written determination of appeal shall include:

289:28 Managed Care Law; Grievance Procedures. Amend RSA 420-J:5, V(a)(7) to read as follows:

(7) [The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency;”] If the appeal involves an adverse determination, a copy of the notice of the right to external review that includes the specific requirements for filing an external review; and

289:29 New Section; Coverage for Dependents. Amend RSA 420-J by inserting after section 6-c the following new section:

420-J:6-d 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.

289:30 Small Employer Reinsurance. Amend RSA 420-K:3, II(g) to read as follows:

(g) Assess members in accordance with the provisions of this chapter, and to make advance interim assessments as may be reasonable and necessary for organizational and interim operating expenses and to pay claims reinsured by the pool. Any such interim assessments shall be credited as offsets against any regular assessments due following the close of the fiscal year.

289:31 Small Employer Reinsurance. Amend RSA 420-K:6, I(b) to read as follows:

(b) In addition to the regular assessment rate, the board may establish a special assessment rate for organizational expenses and to pay claims reinsured by the pool. Notwithstanding RSA 420-G:4, a writer of health insurance may increase the premiums charged by the amount of the special assessment. Any assessment may appear as a separate line item on a policyholder’s bill.

(1) The board shall only establish an interim assessment if the board determines that its funds are or will become insufficient to pay the reinsurance pool’s expense or claims reinsured by the pool, in a timely manner.

(2) The regular assessment rate, and any special assessment rate, shall be subject to the approval of the commissioner. The commissioner shall approve the rate if he or she finds that the amount is required to fulfill the purpose of the reinsurance pool. For the purpose of making this determination, the commissioner may, at the expense of the pool, seek independent actuarial certification of the need for the proposed rate.

289:32 Small Employer Reinsurance. Amend RSA 420-K:2, II to read as follows:

II. On or before July 1, 2005, the commissioner shall give notice to all members of the pool of the time and place for the initial organizational meeting, which shall take place by July 15, 2005. The members shall select the initial board[,] at the organizational meeting and such initial board shall be subject to approval by the commissioner. The members shall elect each subsequent board at the annual meeting of members and each such subsequent board shall be subject to approval by the commissioner. The initial board and each subsequent board shall consist of at least 5 and not more than 9 representatives of members. There shall be no more than one board member on the initial board and each subsequent board representing any one member company. In determining voting rights at the organizational meeting and all subsequent meetings of members, each member shall be entitled to vote in person or by proxy. [The vote] All such votes shall be proportional to the member’s covered lives. To the extent possible, at least 2/3 of [the] members of [the] each board shall be small employer health carriers. At least one member of each board shall be a small employer health carrier with less than $100,000,000 in net small employer health insurance premium in this state. The commissioner, or designee, shall be an ex-officio voting member of the board. In approving selection of [the] each board, the commissioner shall assure that all members are fairly represented. [The membership of all boards subsequent to the initial board shall be approved by the commissioner and shall, to the extent possible, reflect the same distribution of representation as is described in this paragraph.]

289:33 Small Employer Reinsurance. Amend RSA 420-K:7, II to read as follows:

II. Any person or member made a party to any action, suit, or proceeding because the person or member served on the board or on a committee or was an officer or employee of the pool shall be held harmless and be indemnified by the pool against all liability and costs, including the amounts of judgments, settlements, fines or penalties, and expenses and reasonable attorney’s fees incurred in connection with the action, suit, or proceeding. The indemnification shall not be provided on any matter in which the person or member is finally adjudged in the action, suit, or proceeding to have committed a breach of duty involving gross negligence, dishonesty, willful misfeasance, or reckless disregard of the responsibilities of office. Costs and expenses of the indemnification shall be prorated and paid for by all members. The right of indemnification shall not be exclusive of other rights or defenses to which such person or the legal representative or successors of such person, may be entitled to as a matter of law. The commissioner may retain actuarial consultants necessary to carry out his or her responsibilities pursuant to this chapter and such expenses shall be paid by the pool established in this chapter.

289:34 Withholding of Wages; Insurance; Reference Change. Amend RSA 275:48, III to read as follows:

III. An insurer or plan administrator of a self-funded plan shall notify an employee in writing of termination of an employee benefit plan pursuant to the notification requirements of RSA [415:18, VII(g)(4)] 415:18, XVI or the Employee Retirement Income Security Act, as applicable.

289:35 Insurance; Applicable Statutes; Reference Change. Amend RSA 420-A:2 to read as follows:

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 415:18, V[, RSA 415:18, VII(g)], RSA 415:18, VII-a, RSA 415:18, XVI and XVII, RSA 415:18-a, RSA 415:18-j, RSA 415:18-o, RSA 415:18-r, 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.

289:36 Health Maintenance Organizations; Reference Change. Amend RSA 420-B:20, III to read as follows:

III. The requirements of RSA 400-A:39, RSA 401-B, RSA 402-C, RSA 404-F, RSA 415:6-g, RSA 415:6-m[, RSA 415:18, VII(g)], RSA 415:18, VII-a, RSA 415:18, XVI and XVII, RSA 415:18-j, RSA 415:18-r, RSA 415-A, RSA 415-F, RSA 420-G, and RSA 420-J shall apply to health maintenance organizations.

289:37 Delta Dental Plan of New Hampshire; Scope of Chapter; Reference Change. Amend RSA 420-F:1, III to read as follows:

III. Delta shall be governed by this chapter and shall be exempt from this title, except for the provisions of RSA 400-A:39, RSA 402-C, RSA 404-F, RSA [415:18, VII(g)(1)] 415:18, XVI, relative to continuation of dental insurance, and 1961, 345; provided, however, if any of the provisions of 1961, 345 are inconsistent with this chapter the provisions of this chapter shall prevail. Delta and its agents shall be subject to the fees prescribed for health service corporations under RSA 400-A:29, VII.

289:38 Individual Health Insurance Market; Eligibility. Amend RSA 404-G:5-e, V(c) to read as follows:

(c) The individual’s premiums are paid for or reimbursed by the health care provider or the individual’s premiums are paid by any government sponsored program or government agency, except if the person is [an “eligible individual” as defined in section 2741(b) of the Public Health Service Act] eligible under subparagraphs I(d) or (e). Nothing in this subparagraph shall be construed to prevent the association from receiving or using non-assessment funds, including but not limited to federal, state, foundation, or other grants or donations from any source to further the purposes of this chapter.

289:39 New Paragraph; Health Coverage; Enrollment. Amend RSA 420-G:8 by inserting after paragraph II the following new paragraph:

II-a. Notwithstanding the provisions of paragraphs I-a and II, small employers who are self-employed individuals shall have 90 days from the date their business is first established to enroll in a plan. Health carriers shall make their plans available to such individuals for effective dates beginning on the first day of the month following enrollment.

289:40 Contingent Renumbering. If HB 790-FN of the 2007 legislative session becomes law, then RSA 420-C:4-a and RSA 420-C:4-b, as inserted by section 18 of this act, shall be renumbered as RSA 420-C:4-b and RSA 420-C:4-c, respectively.

289:41 Repeal. RSA 415:18, X and XI, relative to conversion privilege, are repealed.

289:42 Effective Date.

I. Sections 30 through 33 of this act shall take effect 60 days after its passage.

II. The remainder of this act shall take effect January 1, 2008.

Approved: July 3, 2007

Effective: I. Sections 30 through 33 shall take effect September 1, 2007.

II. Remainder shall take effect January 1, 2008