Section 420-B:8 Forms of Evidence of Coverage.
I. No evidence of coverage, or amendment thereto, shall be issued to any person in this state until a copy of the evidence of coverage, or amendment thereto including all rates to be charged, has been filed with and approved by the commissioner.
II. Every health maintenance organization shall provide evidence of coverage to each enrolled participant. If the enrolled participant obtains coverage through an insurance policy or a contract issued by a hospital, medical or health service corporation, whether by option or otherwise, the insurer or hospital or medical service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage. When a group of enrolled participants comprise a family unit a single evidence of coverage of said family unit shall be sufficient.
III. All forms of evidence of coverage issued by the health maintenance organization to enrolled participants, or other marketing documents purporting to describe the organization's health care services, shall contain clear and complete information indicating:
(a) The health care services and other benefits to which the enrolled participant is entitled;
(b) Any exclusions or any limitations on services or any other benefits to be provided, including any deductible or co-payment feature or any restrictions relating to pre-existing conditions;
(c) Where and in what manner information is available as to how services may be obtained;
(d) The predetermined periodic rate of payment for health care services and other benefits and other charges, if any, which the enrolled participant is obliged to pay; and
(e) All criteria relating to disenrollment or denials of re-enrollment.
(f) With respect to subscribers with Medicare supplement insurance benefits, the health maintenance organization shall allow each such subscriber a period of at least one year after the incurral of a covered expense within which the subscriber shall furnish any proof of loss required by the insurer. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and such proof was furnished as soon as was reasonably possible.
III-a. Every health maintenance organization shall state on its forms of evidence of coverage that a maternity benefits rider will be made available at the request of the enrolled participant, if maternity care is not covered in the insurance policy, contract or evidence of coverage. Nothing in this paragraph shall be construed to apply to supplemental health insurance and disability insurance policies.
III-b. The coverage of any family member insured by such policy, pursuant to RSA 420-B:8-aa, I, who is mentally or physically incapable of earning his or her own living as of the date on which such dependent's status as a covered family member would otherwise expire because of age, shall continue under such policy while such policy remains in force or is replaced by another policy as long as such incapacity continues and as long as such dependent remains chiefly financially dependent on the policyholder or the employee or his or her estate is chargeable for the care of such dependent; provided, that due proof of such incapacity is received by the insurer within 31 days of such expiration date. If such coverage is continued in accordance with this paragraph, such dependent shall be entitled upon the termination of such incapacity to coverage offered by the New Hampshire high risk pool under RSA 404-G.
III-c. Non-group contracts issued by a health maintenance organization shall contain the following provision: Insurance with Other Insurers. If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or an expense incurred basis, payment shall not be prorated or reduced. In such a case, the insured shall be entitled to payment from both insurers. However, the provisions of this paragraph shall not prohibit the issuance of contracts including a ""benefits deductible.'' The term ""benefits deductible,'' as used in this paragraph means the term as defined in RSA 415:6, II(4).
IV. (a) The periodic rate of payment for health care services and other benefits and other charges, if any, included in any form of evidence of coverage shall be reasonable in relation to the benefits and health care services provided and not excessive, inadequate or discriminatory.
(b) A grace period shall be allowed the enrolled participant for making any payment due under the contract. Such period shall not be less than 10 days.
V. No health maintenance organization authorized under this chapter shall cancel the enrollment of an enrolled participant or refuse to transfer an enrolled participant from a group to an individual basis for reasons relating to health status.
VI. All advertising intended for use in this state whether through written, radio, or television medium shall be submitted to the commissioner of this state for review and approval by the commissioner prior to use, except that the commissioner may waive prior approval for any such materials which the department of health and human services has approved for use in the medicaid program.
VII. The commissioner may, at any time, after a hearing, if one is requested, withdraw his approval of any advertising, evidence of coverage or amendment thereto on any of the grounds stated as material to approval. It shall be unlawful for any health maintenance organization to issue any evidence of coverage or amendment thereto after the effective date of such withdrawal of approval.
Source. 1977, 282:1. 1993, 167:3; 196:6. 1995, 112:17. 1996, 188:8. 1997, 282:2, eff. Jan. 1, 1998. 2009, 235:10, eff. Sept. 14, 2009.