N.H. Admin. Code § Ins 7001.06

Current through Register No. 49, December 5, 2024

Section Ins 7001.06 - Required Policy Provisions

(a) A short term limited duration health insurance policy shall comply with the following provisions:

(1) The date of delivery shall be the date shown by the policyholder's records or by his or her memory, unless the insurer has adopted a procedure to obtain a policyholder's dated and signed receipt for the delivery of the policy;

(2) Diseases to be excluded from coverage shall be stated with sufficient clarity to be readily identifiable by the insured;

(3) A policy may:

a. Require that the insured incur expenses that he or she is legally required to pay; and

b. Exclude charges that would not have been made if no insurance existed;

(5) Where the insurer reserves the right to cancel, the provisions of RSA 415:6, II(8) shall be delineated in the policy;

(6) With respect to all short term limited duration health insurance policies to which the refund provisions of RSA 415:6, II(8) do not apply, the insurer shall provide:

a. A refund of unearned premium upon a request for cancellation of the policy by the insured;

b. The period for which a refund is to be made measured from the date the request for cancellation is received by the insurer, or such later date as may be specified in the request, to the date to which premiums have been paid; and

c. A refund amount of not less than 80 percent of the pro-rata unearned premium for such period;

(7) Hospital, medical, and surgical expenses shall be covered, to an aggregate maximum of not less than $1,000,000 per covered member;

(8) Policyholder coinsurance percentage per policy period per covered person shall not exceed 50 percent of covered charges, provided that the coinsurance or co-payment out-of-pocket maximum after any deductibles shall not exceed $10,000 per person per policy period;

(9) The maximum out-of-pocket per family per policy period shall not exceed 3 times the individual out-of-pocket maximum;

(10) Covered services shall include, at a minimum:

a. Daily hospital room and board expenses at the semiprivate room rate;

b. Hospital services and supplies;

c. Surgical services:

d. Anesthesia services;

e. In-hospital medical and diagnostic services;

f. Emergency care services;

g. All individual policy mandates under New Hampshire statute;

h. In-hospital prescription drugs and medications;

i. Out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis where coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and

j. Not fewer than 3 of the following additional benefits:

1. In-hospital private duty registered nurse services;

2. Convalescent nursing home care;

3. Diagnosis and treatment by a radiologist or physiotherapist;

4. Rental of special medical equipment, as defined by the insurer in the policy;

5. Artificial limbs or eyes, casts, splints, trusses, or braces;

6. Treatment for functional nervous disorders and mental and emotional disorders; or

7. Out-of-hospital prescription drugs and medications;

(11) The minimum benefits required by (10) above may be subject to all applicable deductible, coinsurance, and general policy exceptions and limitations; and

(12) Except as authorized by this part through the application of special or internal limitations, a short term limited duration health policy shall be designed to cover, after any deductibles or coinsurance provisions are met, the usual and customary or reasonable and customary charges, as determined consistently by the carrier, or another rate agreed to between the insurer and provider for covered services up to the lifetime policy maximum.

(b) Short term limited duration health insurance policies that are network based shall comply with individual policy provisions of RSA 420-J and Ins 2700.

(c) The schedule of benefits shall be included within the policy.

N.H. Admin. Code § Ins 7001.06

Derived from Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12798, Effective 6/10/2019, Expires 6/10/2029.